Application of nursing process and nursing diagnosis : an interactive text for diagnostic reasoning / Marilynn E. Doenges, Mary Frances Moorhouse.

Format:

Book

Author/Creator:

Doenges, Marilynn E., 1922-

Contributor:

Moorhouse, Mary Frances, 1947-

Language:

English

Subjects (All):

Nursing.

Nursing assessment.

Nursing diagnosis.

Nursing Process.

Nursing Diagnosis--methods.

Medical Subjects:

Nursing Process.

Nursing Diagnosis--methods.

Physical Description:

xxi, 320 pages : illustrations ; 23 cm

Edition:

Fourth edition.

Place of Publication:

Philadelphia, Pa. : F.A. Davis, [2003]

Summary:

This step-by-step guide explains the systematic approach of the nursing process and reinforces it with interactive exercises. Given the shift in focus of the nursing process from a problem-oriented approach to the wellness approach of a positive client-need relationship, this new edition has been updated and revised for today's nursing. In this edition, the vignettes, practice activities, work pages, and case studies provide an opportunity to examine situations in practice, consider alternatives, and evaluate outcomes for clients across the life span. Worksheets and tear-out pages allow students an opportunity to practice what they've learned.

Contents:

Chapter 1 The Nursing Process: Delivering Quality Care 1

The Nursing Profession 1

The Nursing Process 3

How the Nursing Process Works 4

Practice Advantages of the Nursing Process 5

Classical Publications 11

Current Publications 11

Chapter 2 The Assessment Step: Developing the Client Database 13

The Client Database 13

Framework for Data Collection 14

The Interview Process 14

The Nursing Interview: Questioning and Listening 20

The Client History 20

Guidelines for History-Taking 22

Listen Carefully 22

Active Listening 22

Objectivity 22

Manageable Detail 22

Sequence Information 23

Document Clearly 23

Record Data in a Timely Way 23

Physical Examination: The Hands-on Phase 23

Focus and Preparation 23

Assessment Methods 24

Follow-Up Considerations 25

Laboratory Tests and Diagnostic Procedures: Supporting Evidence 25

Organizing Information Elements 27

Clustering the Collected Data 27

Reviewing and Validating Findings 27

Genogram References 36

Chapter 3 The Diagnosis or Need Identification Step: Analyzing the Data 37

Defining Nursing Diagnosis 39

The Use of Nursing Diagnoses 39

Identifying Client Needs 43

Diagnostic Reasoning: Analyzing the Client Database 43

Step 1 Problem-Sensing 43

Step 2 Rule-Out Process 51

Step 3 Synthesizing the Data 51

Step 4 Evaluating or Confirming the Hypothesis 52

Step 5 List the Client's Needs 53

Step 6 Re-evaluate the Problem List 53

Other Considerations for Need Identification 57

Writing a Client Diagnostic Statement: Using Pes Format 61

Nursing Language, Classification, Theory, and Taxonomy 71

Texts 71

Validation of Nursing Diagnoses 72

Specific Nursing Diagnoses 73

Accuracy of Nursing Diagnoses 73

Wellness (Health Promotion) 74

Omaha System 74

Home Health Care Classification 75

Patient Care Data Set 75

Perioperative Nursing Care Data Set 75

Chapter 4 The Planning Step: Creating the Plan of Care 77

Setting Priorities for Client Care 78

Establishing Client Goals 80

Identifying Desired Outcomes 81

Selecting Appropriate Nursing Interventions 85

The Client Plan of Care 90

Discharge Planning 93

Documenting the Plan of Care 93

Validating the Plan of Care 94

Professional Concerns Related to the Plan of Care 94

Putting it All Together 97

A Complementary Approach

Mind Mapping 97

Nursing Outcomes 103

Nursing Interventions 103

Nursing Language 104

Chapter 5 The Implementation Step: Putting the Plan of Care into Action 105

Identifying Caregiving Priorities 105

Ethical and Legal Concerns 107

Delivering Nursing Care 108

Ongoing Data Collection 111

Documentation 111

Verbal Communication with the Healthcare Team 111

Advance Directives, Ethics, and Legal Aspects 117

Change-of-Shift Report 118

Chapter 6 The Evaluation Step: Determining Whether Desired Outcomes Have Been Met 119

Reassessment 120

Modification of the Plan of Care 122

Termination of Services 125

Enhancing Delivery of Quality Care 127

Chapter 7 Documenting the Nursing Process 133

Role of Documentation 134

Progress Notes 134

Staff Communication 134

Evaluation 135

Relationship Monitoring 135

Reimbursement 135

Legal Documentation 136

Accreditation 136

Training and Supervision 136

Techniques for Descriptive Note Writing 138

Judgmental Language 138

Undefined Periods of Time 138

Undefined Quantities 139

Unsupported Qualities 140

Objective Basis for Judgments 140

Descriptive Language 141

Content of Note/Entry 142

Format of Note/Entry 145

Chapter 8 Interactive Care Planning: From Assessment to Client Response 157

Instructions for Case Study 157

Case Study Care Planning Worksheet 158

Care Planning Evaluation Checklist 158

Practicing Critical Thinking 163

Putting Together What You Have Learned about the Nursing Process 165

Admitting Physician's Orders 167

Client Assessment Database 167

Appendix A North American Nursing Diagnosis Association (NANDA) Nursing Diagnoses with Definitions, Related/Risk Factors, and Defining Characteristics 183

Appendix B NANDA Taxonomy II: Definitions of Axes 243

Appendix C Assessment Tools 245

Appendix D NANDA Nursing Diagnoses Organized According to Maslow's Hierarchy of Needs and Nursing Framework: A Health Outcome Classification for Nursing Diagnosis 255

Appendix E Code for Nurses 261

Appendix F Lunney's Ordinal Scale for Degrees of Accuracy of a Nursing Diagnosis 263

Appendix G Self-Monitoring of Accuracy Using the Integrated Model: A Guide 265

Appendix H Clinical (Critical) Pathways: A Sample 267

Appendix K Nursing Outcomes Classification 281.

Notes:

Includes bibliographical references and index.

ISBN:

0803610661

OCLC:

51607869