Application of nursing process and nursing diagnosis : an interactive text for diagnostic reasoning

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This text aims to teach new students to think like nurses and develop diagnostic reasoning and problem-solving skills. Each step of the nursing process is explained and reinforced with interactive activities. Key features include: tear-out worksheets; NANDA diagnoses; and NANDA taxonomy.

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This is the fourth edition of a book that takes the student step-by-step through the nursing process. Its style reinforces critical thinking and diagnostic reasoning, not memorization. The previous edition was published in 2000. The purpose is to teach the nursing process and its application to a clinical setting. It applies the ANA and JCAHO standards and relates them to the nursing process. The objectives are worthy and met. It is designed for nursing students, both LPN or RN. Authors are known experts in the nursing process. The book leads the student through the steps of the nursing process starting with an overview of the problem-solving framework. The areas that are unique to this book are the inclusion of concept or mind mapping to determine a plan of care which includes an illustration that helps the student to understand how to make use of data collected from patient assessment; side bar notes to reinforce content such as the definition of nursing; boxes that highlight an ANA standard and its application; patient vignettes that highlight the nurse's role in the healthcare team; tear-out worksheets at the end of the chapters that students can use to practice the nursing process; and appendixes that include NANDA, NIC, NOC, common terminology and charting terms, learning activities, critical pathways, and scales to measure outcomes. Shortcomings of the book are few. Most of the references are from 1998 or earlier. There have been some updates, more is certain areas than others. They do reflect pertinent secondary sources of information, most textbooks. However, we are trying to promote evidence-based practice, it would be helpful to see more application articles and primary sources. In addition the move to electronic medical records is having a significant impact on nursing documentation, application of nursing process, yet there is no real mention of this change in practice. The authors, as usual, present material in easy to digest chunks. They give the student helpful hints along the way to support each step of the process. Few books that discuss the nursing process clearly make the tie to ANA and JCAHO standards. The update of the NANDA II taxonomy and encouragement of content mapping are two areas that are consistent with movements in education these days. The problem that educators have in using any of the current nursing process books is how to make the transition from the long learning forms to what is used in everyday practice. No book totally bridges that gap or helps the faculty to guide the student in this direction. This book does the best job of attempting to present educational content that is truly applicable in the clinical setting that I have found. Carole A. Kenner, RNC, DNS, FAAN(University of Illinois at Chicago). Copyright 2001, Doody Publishing

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List of Practice Activities and Work Pages	p. xxi
Chapter 1 The Nursing Process: Delivering Quality Care	p. 1
The Nursing Profession	p. 1
The Nursing Process	p. 3
How the Nursing Process Works	p. 4
Practice Advantages of the Nursing Process	p. 5
Summary	p. 7
Bibliography	p. 11
Suggested Readings	p. 11
Classical Publications	p. 11
Current Publications	p. 11
Chapter 2 The Assessment Step: Developing the Client Database	p. 13
The Client Database	p. 13
Framework for Data Collection	p. 14
The Interview Process	p. 14
The Nursing Interview: Questioning and Listening	p. 20
The Client History	p. 20
Guidelines for History-Taking	p. 22
Listen Carefully	p. 22
Active Listening	p. 22
Objectivity	p. 22
Manageable Detail	p. 22
Sequence Information	p. 23
Document Clearly	p. 23
Record Data in a Timely Way	p. 23
Physical Examination: The Hands-on Phase	p. 23
Focus and Preparation	p. 23
Assessment Methods	p. 24
Follow-Up Considerations	p. 25
Laboratory Tests and Diagnostic Procedures: Supporting Evidence	p. 25
Organizing Information Elements	p. 27
Clustering the Collected Data	p. 27
Reviewing and Validating Findings	p. 27
Summary	p. 30
Bibliography	p. 35
Suggested Readings	p. 35
Genogram References	p. 36
Chapter 3 The Diagnosis or Need Identification Step: Analyzing the Data	p. 37
Defining Nursing Diagnosis	p. 39
The Use of Nursing Diagnoses	p. 39
Identifying Client Needs	p. 43
Diagnostic Reasoning: Analyzing the Client Database	p. 43
Step 1 Problem-Sensing	p. 43
Step 2 Rule-Out Process	p. 51
Step 3 Synthesizing the Data	p. 51
Step 4 Evaluating or Confirming the Hypothesis	p. 52
Step 5 List the Client's Needs	p. 53
Step 6 Re-evaluate the Problem List	p. 53
Other Considerations for Need Identification	p. 57
Writing a Client Diagnostic Statement: Using Pes Format	p. 61
In a Nutshell	p. 65
Summary	p. 66
Bibliography	p. 71
Suggested Readings	p. 71
Nursing Language, Classification, Theory, and Taxonomy	p. 71
Texts	p. 71
Validation of Nursing Diagnoses	p. 72
Specific Nursing Diagnoses	p. 73
Accuracy of Nursing Diagnoses	p. 73
Wellness (Health Promotion)	p. 74
Omaha System	p. 74
Home Health Care Classification	p. 75
Patient Care Data Set	p. 75
Perioperative Nursing Care Data Set	p. 75
Chapter 4 The Planning Step: Creating the Plan of Care	p. 77
Setting Priorities for Client Care	p. 78
Establishing Client Goals	p. 80
Identifying Desired Outcomes	p. 81
Selecting Appropriate Nursing Interventions	p. 85
The Client Plan of Care	p. 90
Discharge Planning	p. 93
Documenting the Plan of Care	p. 93
Validating the Plan of Care	p. 94
Professional Concerns Related to the Plan of Care	p. 94
Putting it All Together	p. 97
A Complementary Approach--Mind Mapping	p. 97
Summary	p. 97
Bibliography	p. 103
Suggested Readings	p. 103
Nursing Outcomes	p. 103
Nursing Interventions	p. 103
Nursing Language	p. 104
Chapter 5 The Implementation Step: Putting the Plan of Care into Action	p. 105
Identifying Caregiving Priorities	p. 105
Ethical and Legal Concerns	p. 107
Delivering Nursing Care	p. 108
Ongoing Data Collection	p. 111
Documentation	p. 111
Verbal Communication with the Healthcare Team	p. 111
Summary	p. 115
Suggested Readings	p. 117
Advance Directives, Ethics, and Legal Aspects	p. 117
Change-of-Shift Report	p. 118
Chapter 6 The Evaluation Step: Determining Whether Desired Outcomes Have Been Met	p. 119
Reassessment	p. 120
Modification of the Plan of Care	p. 122
Termination of Services	p. 125
Enhancing Delivery of Quality Care	p. 127
Summary	p. 127
Bibliography	p. 131
Suggested Readings	p. 131
Chapter 7 Documenting the Nursing Process	p. 133
Role of Documentation	p. 134
Progress Notes	p. 134
Staff Communication	p. 134
Evaluation	p. 135
Relationship Monitoring	p. 135
Reimbursement	p. 135
Legal Documentation	p. 136
Accreditation	p. 136
Training and Supervision	p. 136
Techniques for Descriptive Note Writing	p. 138
Judgmental Language	p. 138
Undefined Periods of Time	p. 138
Undefined Quantities	p. 139
Unsupported Qualities	p. 140
Objective Basis for Judgments	p. 140
Descriptive Language	p. 141
Content of Note/Entry	p. 142
Format of Note/Entry	p. 145
Summary	p. 151
Bibliography	p. 156
Suggested Readings	p. 156
Chapter 8 Interactive Care Planning: From Assessment to Client Response	p. 157
Instructions for Case Study	p. 157
Case Study Care Planning Worksheet	p. 158
Care Planning Evaluation Checklist	p. 158
Practicing Critical Thinking	p. 163
Conclusion	p. 165
Putting Together What You Have Learned about the Nursing Process	p. 165
Admitting Physician's Orders	p. 167
Client Assessment Database	p. 167
Worksheets for Students' Use	p. 174
Appendix A North American Nursing Diagnosis Association (NANDA) Nursing Diagnoses with Definitions, Related/Risk Factors, and Defining Characteristics	p. 183
Appendix B NANDA Taxonomy II: Definitions of Axes	p. 243
Appendix C Assessment Tools	p. 245
Appendix D NANDA Nursing Diagnoses Organized According to Maslow's Hierarchy of Needs and Nursing Framework: A Health Outcome Classification for Nursing Diagnosis	p. 255
Appendix E Code for Nurses	p. 261
Appendix F Lunney's Ordinal Scale for Degrees of Accuracy of a Nursing Diagnosis	p. 263
Appendix G Self-Monitoring of Accuracy Using the Integrated Model: A Guide	p. 265
Appendix H Clinical (Critical) Pathways: A Sample	p. 267
Appendix I Common Medical Abbreviations	p. 273
Appendix J Glossary	p. 277
Appendix K Nursing Outcomes Classification	p. 281
Appendix L Keys to Practice Activities	p. 283
Appendix M Keys to Chapter Work Pages	p. 297
Index	p. 311

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