Applying nursing process : a tool for critical thinking / Rosalinda Alfaro-LeFevre.

Includes bibliographical references and index.

Contents

Chapter 1 Nursing Process Overview
What Is the Nursing Process and Why Learn About It?
What Is it?
Nursing Process Characteristics That Promote Critical Thinking
Why Learn About it?
Steps of the Nursing Process
Relationships Among the Steps of the Nursing Process
Assessment and Diagnosis
Diagnosis and Planning
Planning and Implementation
Implementation and Evaluation
Evaluation and the Other Steps in the Nursing Process
What Are the Benefits of Using the Nursing Process?
Nursing Process in Context of Today's Changing World
Today's Health Care Reality
Patient Safety Is Top Priority
Ethics: Advocating for Patients' Rights
Seven Ethical Principles
Including Patient Partners While Following HIPAA Rules
Critical Thinking Exercise I: Using the Nursing Process in a Changing World
What's the Difference Between Nursing Process and Critical Thinking?
How to Become a Critical Thinker
Critical Thinking: Get the Picture?
Willingness and Ability to Care
Willingness to Care
Being Able to Care
Understanding Ourselves
Understanding Others
Critical Thinking Exercise II: Critical Thinking and Willingness and Ability to Care
Summary

Chapter 2 Assessment
Assessment: The First Step to Determining Health Status
Characteristics of an Assessment That Promotes Critical Thinking
Six Activities of Assessment
Collecting Data
What Resources Do You Use?
How to Ensure Comprehensive Data Collection
Data Base (Start of Care) Versus Focus Assessment
Data Base (Start of Care) Assessment
Focus Assessment
Health Promotion: Screening for Prevention and Early Diagnosis
Helping Patients Make Informed, Joint Decisions
The Nursing Interview and Physical Assessment
Ethical, Cultural, and Spiritual concerns
The Nursing Interview
Guidelines: Promoting a Caring Interview
How to Establish Rapport
How to Listen
How to Ask Questions
How to Observe
Physical Assessment
Guidelines: Doing a Physical Assessment
Checking Diagnostic Studies
Critical Thinking Exercise III: The Nursing Interview and Physical Assessment
Identifying Subjective and Objective Data
Identifying Cues and Making Inferences
Validating (Verifying) Data
Critical Thinking Exercise IV: Subjective and Objective Data; Cues and Inferences;
Validating Data
Organizing (Clustering) Data
Clustering Data According to Purpose
Critical Thinking Exercise V: Organizing (Clustering) Data
Identifying Patterns/Testing First Impressions
Reporting and Recording
Deciding What to Report
Deciding What's Abnormal
Guidelines: Reporting Significant Findings
General Guidelines
Guidelines for Phone Reports
Deciding What to Record
Guidelines: Recording the Nursing Data Base
Critical Thinking Exercise VI: Recognizing Abnormal Data, Deciding What's
Relevant
Summary

Chapter 3 Diagnosis
From Assessment to Diagnosis: A Pivotal Point
New ANA Standard Related to Diagnosis
Nurses' Growing Responsibilities as Diagnosticians
Diagnose and Treat (DT) Versus. Predict, Prevent, Manage, and Promote (PPMP)
Multidisciplinary Practice
Disease Management
Point-of-Care Testing
Critical Pathways (Clinical Pathways, CareMapsTM)
Advantages of Critical Paths
Disadvantages of Critical Paths
Informatics and Computer-Assisted Diagnosis
Using Standard or Recognized Terminologies
Changing Thinking About What Terms to Use
How to Use Standard Languages.
Computer-Assisted Diagnosis
Benefits of Computer-Assisted Diagnosis
Limitations of Computer-Assisted Diagnosis
Becoming a Competent Diagnostician
Key Terms Related to Diagnosis
Recognizing Risk Factors: The Key to Proactive Approaches
Critical Thinking Indicators (CTIs) Related to Diagnosis
Critical Thinking Exercise VII: Nurses' Responsibilities as Diagnosticians; Key
Terms Related to Diagnois; Differentiating Between Nursing Diagnoses and
Other Problems
Learning How to Make Definitive Diagnoses
Fundamental Principles and Rules of Diagnostic Reasoning
Becoming a Competent Diagnostician: Old Versus Current Thinking
Patients as Partners in Diagnosis
Clarifying Causes and Contributing (Risk) Factors
Avoiding Diagnostic Errors
Identifying Nursing Diagnoses
Guidelines: Identifying Nursing Diagnoses
Mapping Diagnoses
Using the PES (or PRS) Method for Stating Nursing Diagnoses
Guidelines: Avoiding Errors When Writing Diagnostic Statements
Critical Thinking Exercise VIII: Recognizing, Mapping and Stating Nursing
Diagnoses
Identifying Potential Complications
Guidelines: Identifying Potential Complications
Identifying Problems Requiring Multidisciplinary Approaches
Critical Thinking Exercise IX: Predicting Potential Complications/Identifying
Problems Requiring a Multidisciplinary Approach, Pulling It All Together
Summary

Chapter 4 Planning
Four Main Purposes of the Plan of Care
Initial Versus Ongoing Planning
Applying Standards
Pain Management, Patient Safety, and Error-Prevention Standards
Computers and Standard Plans
Attending to Urgent Priorities
Clarifying Expected Outcomes (Results)
Outcomes Versus 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
Critical Thinking Exercise X: Applying Standards, Setting Priorities, and Clarifying
Expected Outcomes
Determining Nursing Interventions
Assessment-Monitoring Health Status
Teaching-The Key to Empowerment
Guidelines: Planning Teaching
Counseling-Helping People Make Informed Choices
Consulting and Referring-The Cornerstone of Multidisciplinary Approaches
Individualizing Interventions
Evidence-Based Practice: Weigh Risks and Benefits, Be Proactive
Guidelines: Individualizing Nursing Orders
Making Sure the Plan Is Adequately Recorded
Guidelines: Computerized Charting
Multidisciplinary Plans
Critical Thinking Exercise XI: Determining Interventions and Recording Nursing
Orders
Summary

Chapter 5 Implementation
Implementation: Putting the Plan Into Action
Critical Think Indicators (CTIs) Related to Implementation
Preparing for Report and Getting Report
Preparing for Report
Getting Report
Setting Daily Priorities
Strategies: Prioritizing Care for Several Patients
Delegating Care, Not Accountability
Coordinating Care
Monitoring Responses: Assessing and Reassessing
Performing Nursing Interventions
Be Proactive-Promote Safety, Comfort, and Efficiency
Implementation and Evidence-based Practice
Guidelines: Preparing to Act
Thinking Critically: What to Do If Things Go Wrong
Case Management: Critical Paths and Care Variances
Ethical/Legal Concerns
Critical Thinking Exercise XII: Delegating, Case Management, Critical Paths, and
Care Variances
Charting
Five Purposes of Charting
Different Ways of Charting
Principles of Effective Charting
Avoiding Dumping Syndrome With Computerized Charting
Learning to Chart Effectively
Guidelines: Charting During Implementation
Memory-Jogs Used for Charting
Critical Thinking Exercise XIII: Principles of Effective Charting
Giving Change-of-Shift Report
Guidelines: Giving Change-of-Shift Reports
Keeping the Plan Up to Date and Evaluating Your Day
Summary

Chapter 6 Evaluation
Critical Evaluation: Excellence in Health Care Delivery
Evaluation and the Other Steps in the Nursing Process
Evaluating an Individual Plan of Care
Guidelines: Determining Outcome Achievement
Identifying Variables (Factors) Affecting Outcome Achievement
Deciding Whether to Discharge the Patient
Critical Thinking Exercise XIV: Determining Outcome Achievement, Identifying
Variables Affecting Achievement, and Deciding Whether to Discharge The
Patient
Quality Improvement (QI)
The Agency for Health Quality and Research (AHRQ)
Consumer Satisfaction: Maximizing Value
Health Care Systems: Constantly Interacting and Affecting Outcomes
Three Types of Evaluation: Outcome, Process, and Structure
Staff Nurses' Role
Preventing Mistakes and Infection Transmission
Critical Thinking Exercise XV: Quality Improvement
Summary