Fundamentals of Nursing : The Art and Science of Person-Centered Care

Fundamentals of Nursing The Art and Science of Person-Centered Care CONTENTS ACKNOWLEDGMENTS PREFACE LEARNING EXPERIENCE ORGANIZATION Unit I, Foundations of Nursing Practice Unit II, Health Care Delivery Unit III, Person-Centered Care and the Nursing Process Unit IV, Promoting Health Across the Lifespan Unit V, Actions Basic to Nursing Care Unit VI, Promoting Healthy Physiologic Responses Unit VII, Promoting Healthy Psychosocial Responses THEMES Thoughtful Practice and Person-Centered Care Emphasis on Partnering With Patients, Family, and Professional Caregivers Integrated Nursing Process Nursing as an Art and Science Health and Health Disparities Orientation Holistic Care Across the Lifespan Attention to Special Needs of the Older Person Critical Thinking and Clinical Reasoning Healthy Work Environments Focus on Nursing Skills Focus on Community and Expanded Nursing Roles Focus on Safety Evidence-Based Practice Up-to-Date Clinical and Practice Information Self-Assessment Guides SPECIAL FEATURES A FULLY INTEGRATED COURSE EXPERIENCE Lippincott CoursePoint: An Adaptive Learning Experience Lippincott CoursePoint+ SIMULATION, SKILLS, AND VIDEO RESOURCES ADDITIONAL MEDIA AND PRINT RESOURCES Additional Instructor Assessment and Preparation Resources REVIEWERS CONTRIBUTORS HOW TO USE Fundamentals of Nursing HERE’S HOW TO GET STARTED! FOLLOW THE STORY LINES! GET READY TO LEARN! STAY CURRENT ON SAFETY, TECHNOLOGY, AND LEGAL DEVELOPMENTS! DEVELOP CRITICAL THINKING AND CLINICAL REASONING SKILLS! MAKE REFLECTIVE PRACTICE AN ESSENTIAL PART OF YOUR PROFESSIONAL PRACTICE! MASTER NURSING PROCESS! DEVELOP THE NECESSARY SKILLS! PROMOTE HEALTH AND WELLNESS! BE A PATIENT ADVOCATE! GAIN NEW INSIGHTS! EXAMINE THE EVIDENCE! PREPARE FOR NCLEX! COORDINATE YOUR STUDY PLAN! LIPPINCOTT COURSEPOINT IN MEMORIAM Research in Nursing BRIDGING THE GAP TO EVIDENCE-BASED PRACTICE Guidelines for Nursing Care Case Studies in this Book TWO-PART CASES THAT UNFOLD ACROSS CHAPTERS UNIT I: Foundations of Nursing Practice Unit II: Health Care Delivery Unit III: Person-Centered Care and the Nursing Process Unit IV: Promoting Health Across the Lifespan Unit V: Actions Basic to Nursing Care Unit VI: Promoting Healthy Physiologic Responses Unit VII: Promoting Healthy Psychosocial Responses CASES THAT UNFOLD WITHIN CHAPTERS Unit I: Foundations of Nursing Practice Unit II: Health Care Delivery Unit III: Person-Centered Care and the Nursing Process Unit V: Actions Basic to Nursing Care Unit VI: Promoting Healthy Physiologic Responses Unit VII: Promoting Healthy Psychosocial Responses 1 Introduction to Nursing HISTORICAL PERSPECTIVES ON NURSING Development of Nursing from Early Civilizations to the 16th Century Florence Nightingale and the Birth of Modern Nursing Development of Nursing from the 19th to 21st Centuries DEFINITIONS OF NURSING NURSING’S AIMS AND COMPETENCIES Promoting Health Preventing Illness Restoring Health Facilitating Coping With Disability and Death NURSING AS A PROFESSIONAL DISCIPLINE EDUCATIONAL PREPARATION FOR NURSING PRACTICE Practical and Vocational Nursing Education Registered Nursing Education Diploma in Nursing Associate Degree in Nursing Baccalaureate in Nursing Emerging Entry Points Graduate Education in Nursing Continuing Education In-Service Education PROFESSIONAL NURSING ORGANIZATIONS International Nursing Organization National Nursing Organizations American Nurses Association National League for Nurses American Association of Colleges of Nursing National Student Nurses Association Specialty Practice and Special-Interest Nursing Organizations GUIDELINES FOR NURSING PRACTICE Standards of Nursing Practice Nurse Practice Acts and Licensure Code of Ethics and Professional Values Nursing Process CURRENT TRENDS IN HEALTH CARE AND NURSING SELF-CARE DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 2 Theory, Research, and Evidence-Based Practice NURSING KNOWLEDGE Sources of Knowledge Traditional Knowledge Authoritative Knowledge Scientific Knowledge Significance of Knowledge Sources Historical Influences on Nursing Knowledge Nightingale’s Contributions Societal Influences on Nursing Knowledge NURSING THEORY Interdisciplinary Base for Nursing Theories General Systems Theory Adaptation Theory Developmental Theory Nursing Theories Common Concepts in Nursing Theories Nursing Theory in Clinical Practice NURSING RESEARCH The Evolution of Nursing Research Methods of Conducting Nursing Research Quantitative Research Methods Qualitative Research Methods Protection of the Rights of Human Subjects Application of Research to Practice EVIDENCE-BASED PRACTICE Johns Hopkins Nursing Evidence-Based Practice Model Rationale for Using Evidence-Based Practice Steps in Implementing EBP QUALITY IMPROVEMENT DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 3 Health, Wellness, and Health Disparities CONCEPTS OF HEALTH AND WELLNESS CONCEPTS OF ILLNESS AND DISEASE Classifications of Illness Acute Illness Chronic Illness Illness Behaviors STAGE 1: EXPERIENCING SYMPTOMS STAGE 2: ASSUMING THE SICK ROLE STAGE 3: ASSUMING A DEPENDENT ROLE STAGE 4: ACHIEVING RECOVERY AND REHABILITATION Effects of Illness on the Family DISPARITIES IN HEALTH CARE FACTORS AFFECTING HEALTH AND ILLNESS Basic Human Needs The Human Dimensions Physical Dimension Emotional Dimension Intellectual Dimension Environmental Dimension Sociocultural Dimension Spiritual Dimension Self-Concept Risk Factors for Illness or Injury HEALTH PROMOTION AND ILLNESS PREVENTION Primary Health Promotion and Illness Prevention Secondary Health Promotion and Illness Prevention Tertiary Health Promotion and Illness Prevention MODELS OF HEALTH PROMOTION AND ILLNESS PREVENTION The Health Belief Model The Health Promotion Model The Health–Illness Continuum The Agent–Host–Environment Model Stages of Change Model NURSING CARE TO PROMOTE HEALTH AND PREVENT ILLNESS DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 4 Health of the Individual, Family, and Community THE INDIVIDUAL’S BASIC HUMAN NEEDS Physiologic Needs Safety and Security Needs Love and Belonging Needs Self-Esteem Needs Self-Actualization Needs Applying Maslow’s Theory THE FAMILY Family Structures Nuclear Family Single-Parent Family Other Family Structures Family Functions Developmental Tasks of Families The Family in Health and Illness Family Risk Factors Nursing Interventions to Promote Family Health THE COMMUNITY Social Support Systems Community Health Care Structure Economic Resources Environmental Factors Effect on Individuals and Families Nursing in the Community DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 5 Cultural Diversity CONCEPTS OF CULTURAL DIVERSITY AND RESPECT Culture Ethnicity Race Factors Inhibiting Sensitivity to Diversity CULTURAL INFLUENCES ON HEALTH CARE Physiologic Variations Reactions to Pain Mental Health Biological Sex Roles Language and Communication Orientation to Space and Time Food and Nutrition Family Support Socioeconomic Factors Health Disparities CULTURAL INFLUENCES ON HEALTH AND ILLNESS CULTURALLY RESPECTFUL NURSING CARE Cultural Assessment Guidelines for Nursing Care Develop Cultural Self-Awareness Develop Cultural Knowledge Accommodate Cultural Practices in Health Care Respect Culturally Based Family Roles Avoid Mandating Change Seek Cultural Assistance DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 6 Values, Ethics, and Advocacy VALUES Development of Values Values Essential to the Professional Nurse Values Clarification Example of Values Clarification by the Nurse Clinical Applications PATIENT PLACES LOW VALUE ON HEALTH AND HEALTH BEHAVIORS VALUES OF PATIENT AND FAMILY MEMBERS CONFLICT ETHICS Nursing Ethics Theories of Ethics Principle-Based Approach Care-Based Approach Feminist Ethics ETHICAL CONDUCT Moral Agency The Virtues of Nurses Nursing Codes of Ethics Nursing Standards of Practice Bill of Rights for Registered Nurses ETHICAL EXPERIENCE AND DECISION MAKING Moral Distress and Resiliency Conscientious Objection Making Ethical Decisions Ethically Relevant Considerations Examples of Ethical Problems Paternalism Deception Privacy and Social Media Confidentiality Allocation of Scarce Nursing Resources Valid Consent or Refusal Conflicts Concerning New Technologies Unprofessional, Incompetent, Unethical, or Illegal Physician Practice Unprofessional, Incompetent, Unethical, or Illegal Nurse Practice Short Staffing Issues Beginning-of-Life Issues End-of-Life Issues Nurses and Ethics Committees CONFLICTS OF COMMITMENT ADVOCACY IN NURSING PRACTICE Representing Patients Promoting Self-Determination Whistle-Blowing Being Politically Active A Final Note About Trustworthiness DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 7 Legal Dimensions of Nursing Practice LEGAL CONCEPTS Definition of Law Sources of Laws Constitutions Statutory Law Administrative Law Common Law The Court System PROFESSIONAL AND LEGAL REGULATION OF NURSING PRACTICE Nurse Practice Acts Standards Credentialing Accreditation Licensure Certification CRIMES AND TORTS Crime Torts Intentional Torts ASSAULT AND BATTERY DEFAMATION INVASION OF PRIVACY FALSE IMPRISONMENT FRAUD Unintentional Torts NEGLIGENCE AND MALPRACTICE ELEMENTS OF LIABILITY STANDARDS OF CARE Malpractice Litigation NURSE AS DEFENDANT NURSE AS FACT WITNESS NURSE AS EXPERT WITNESS LEGAL SAFEGUARDS FOR THE NURSE Competent Practice Issues That Affect Competent Practice Nurse Fatigue The Impaired Nurse Informed Consent or Refusal Contracts Collective Bargaining Patient Education Executing Provider Orders Delegating Nursing Care Documentation Appropriate Use of Social Media Adequate Staffing Whistle-Blowing Professional Liability Insurance Risk Management Programs Just Culture Incident, Variance, or Occurrence Reports Sentinel Events Never Events Patients’ Rights Good Samaritan Laws Student Liability LAWS AFFECTING NURSING PRACTICE Occupational Safety and Health National Practitioner Data Bank Reporting Obligations Controlled Substances Discrimination and Sexual Harassment Health Insurance Portability and Accountability Act Restraints People With Disabilities Wills Legal Issues Related to Dying and Death DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 8 Communication THE PROCESS OF COMMUNICATION FORMS OF COMMUNICATION Verbal Communication Nonverbal Communication Touch Eye Contact Facial Expressions Posture Gait Gestures General Physical Appearance Mode of Dress and Grooming Sounds Silence Electronic Communication Social Media E-Mail and Text Messages LEVELS OF COMMUNICATION Intrapersonal Communication Interpersonal Communication Group Communication Small-Group Communication Organizational Communication Group Dynamics FACTORS INFLUENCING COMMUNICATION Developmental Level Biological Sex Sociocultural Differences Roles and Responsibilities Space and Territoriality Physical, Mental, and Emotional State Values Environment USING PROFESSIONAL COMMUNICATION IN THE NURSING PROCESS Assessing Diagnosing Outcome Identification and Planning Implementing Evaluating DOCUMENTING COMMUNICATION EFFECTIVE PROFESSIONAL COMMUNICATION Hand-off Communication: SBAR I-SBAR-R and the QSEN Institute SBAR and The Joint Commission: The Hand-off TST Rising Level of Concern Communication: CUS USING PROFESSIONAL COMMUNICATION IN THE HELPING RELATIONSHIP A Helping Relationship Versus a Social Relationship Characteristics of the Helping Relationship Goals of the Helping Relationship Phases of the Helping Relationship Orientation Phase Working Phase Termination Phase Factors Promoting Effective Communication Within the Helping Relationship Dispositional Traits WARMTH AND FRIENDLINESS OPENNESS AND RESPECT EMPATHY HONESTY, AUTHENTICITY, AND TRUST CARING COMPETENCE Rapport Builders SPECIFIC OBJECTIVES COMFORTABLE ENVIRONMENT PRIVACY CONFIDENTIALITY PATIENT VERSUS TASK FOCUS USING NURSING OBSERVATIONS OPTIMAL PACING DEVELOPING PROFESSIONAL THERAPEUTIC COMMUNICATION SKILLS Conversation Skills Listening Skills Silence Touch Humor Interviewing Techniques Open-Ended Question or Comment Closed Question or Comment Validating Question or Comment Clarifying Question or Comment Reflective Question or Comment Sequencing Question or Comment Directing Question or Comment Assertive Versus Aggressive Behaviors and Communication BLOCKS TO COMMUNICATION Failure to Perceive the Patient as a Human Being Failure to Listen Nontherapeutic Comments and Questions Clichés Questions Requiring Only a Yes or No Answer Questions Containing the Words Why and How Questions that Probe for Information Leading Questions Comments that Give Advice Judgmental Comments Changing the Subject Giving False Assurance Gossip and Rumor Disruptive Interpersonal Behavior and Communication Incivility and Bullying Responses to Disruptive Behaviors and Communication IMPAIRED VERBAL COMMUNICATION REFLECTIVE PRACTICE LEADING TO PERSONAL LEARNING DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 9 Teaching and Counseling AIMS of Teaching and Counseling Maintaining and Promoting Health Preventing Illness Restoring Health Facilitating Coping Promoting Outcomes THE NURSE AS A TEACHER Factors Affecting Patient Learning Age and Developmental Level CHILD AND ADOLESCENT LEARNERS ADULT LEARNERS Family Support Networks and Financial Resources Cultural Influences and Language Deficits Health Literacy Promoting Health Literacy IN PATIENTS WHO SMOKE Patient Scenario Nursing Considerations: Tips for Improving Health Literacy Learning Domains Effective Communication Techniques NURSING PROCESS FOR PATIENT AND CAREGIVER TEACHING THE NURSE AS COUNSELOR Types of Counseling Short-Term Counseling Long-Term Counseling Motivational Interviewing Referrals DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 10 Leading, Managing, and Delegating LEADERSHIP Leadership Qualities Personal Leadership Skills Leadership Styles Autocratic Leadership Democratic Leadership Laissez-Faire Leadership Servant Leadership Quantum Leadership Transactional Leadership Transformational Leadership DEVELOPMENT OF THE MAGNET RECOGNITION PROGRAM SIGNIFICANCE OF MAGNET RECOGNITION IMPLEMENTATION OF A “JUST CULTURE” MANAGEMENT Centralized and Decentralized Management Structures Conflict Management and Engagement Managing Change Change Theory Planned Change Resistance to Change THREAT TO SELF LACK OF UNDERSTANDING LIMITED TOLERANCE FOR CHANGE DISAGREEMENTS ABOUT THE BENEFITS OF CHANGE FEAR OF INCREASED RESPONSIBILITY Overcoming Resistance to Change Power IMPLEMENTING LEADERSHIP AND MANAGEMENT SKILLS IN NURSING CARE Patient Care Coordination Clinical Nurse Leader Role Delegating Nursing Care Knowledge of the Administrative Structure Nursing Department Employing Institution or Facility Support for Leadership Training Mentorship Preceptorship Participation in Nursing and Other Professional Organizations Continuing Education Developing Resilience DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 11 The Health Care Delivery System HEALTH CARE: THE BIG PICTURE Access to Health Care Who Are the Uninsured? Shortage of Providers Legislation Addressing Health Care Access Quality and Safety Reliable Care Accountability Matrix Pay for Performance/Value-Based Purchasing Penalties for Excess Readmissions Affordability How Health Care is Financed How the U.S. Health Care Dollar Is Spent How the U.S. Health Care System Compares Internationally HEALTH CARE REFORM ORGANIZING HEALTH CARE: PRIMARY, SECONDARY, AND TERTIARY CARE ORGANIZING HEALTH CARE: HEALTH CARE DELIVERY SYSTEMS AND CARE COORDINATION Health Care Providers and Hospitals Multispecialty Group Practice Community Health Centers Prepaid Group Practice Accountable Care Organizations Medical Homes to Medical Neighborhoods Care Coordination PAYING FOR HEALTH CARE Out-of-Pocket Payment Individual Private Insurance Employer-Based Private Insurance Government Financing Medicare Medicaid Children’s Health Insurance Program Veterans Health Administration HEALTH CARE SETTINGS AND SERVICES Hospitals Classification Size and Services Inpatient and Outpatient Services Nurses’ Role in Hospitals Primary Care Centers Ambulatory Care Centers and Clinics Home Health Care Extended-Care Services Specialized Care Centers and Settings Daycare Centers Mental Health Centers Rural Health Centers Schools Industry Homeless Shelters Rehabilitation Centers Parish Nursing Health Care Services for the Seriously Ill and Dying Respite Care Hospice Services Palliative Care HEALTH CARE FACILITIES Voluntary Facilities Other Government Facilities Public Health Service Public Health Facilities COLLABORATIVE CARE: THE HEALTH CARE TEAM TRENDS AND ISSUES IN HEALTH CARE DELIVERY Focus on Preventive Care Knowledgeable and Engaged Consumers Mobile Health HEALTH CARE: A RIGHT, A PRIVILEGE, OR AN OBLIGATION OF A MORAL SOCIETY? NURSES’ ROLE IN HEALTH CARE REFORM DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 12 Collaborative Practice and Care Coordination Across Settings COMMUNITY-BASED NURSING CARE Qualities of the Community-Based Nurse Knowledgeable and Skilled Independent in Making Decisions Accountable Roles of the Community-Based Nurse Patient Advocate Coordinator of Services Patient and Family Educator CONTINUITY OF CARE COLLABORATIVE PRACTICE Components of Effective Team Structure Core Competencies for Interprofessional Collaborative Practice CARE COORDINATION Validation of Nursing Care Coordination Activities Why Care Coordination Now? The Care Coordinator Populations With Special Care Coordination Needs Admissions, Transfers, and Discharges Admission to an Ambulatory Care Facility Admission to the Hospital PREPARING THE ROOM FOR ADMISSION ADMITTING THE PATIENT TO THE UNIT Transferring Within and Between Health Care Settings TRANSFER WITHIN THE HOSPITAL TRANSFER TO AN EXTENDED CARE FACILITY Discharge from a Health Care Setting DISCHARGE PLANNING GUIDELINES FOR DISCHARGE PLANNING Assessing and Identifying Health Care Needs Setting Goals With the Patient Teaching Meeting Eligibility Requirements for Community-Based Settings EVALUATING DISCHARGE PLANNING EFFECTIVENESS Leaving the Hospital Against Medical Advice HOME HEALTH CARE NURSING Types of Home Health Care Facilities Patients and Family Caregivers Referrals for Home Care Orders for Home Care Safety Considerations Infection Prevention Reimbursement Sources Legal Considerations THE HOME VISIT The Pre-entry Phase of the Home Visit The Entry Phase of the Home Visit Identifying Needs and Determining Interventions Teaching the Patient and Caregivers Documenting Care Given in the Home DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 13 Blended Competencies, Clinical Reasoning, and Processes of Person-Centered Care THOUGHTFUL PRACTICE PERSON-CENTERED CARE Theories of Caring THE PROFESSIONAL NURSE Personal Attributes Knowledge Base Blended Competencies Developing Cognitive Competencies DEVELOPING THE METHOD OF CRITICAL THINKING Purpose of Thinking Adequacy of Knowledge Potential Problems Helpful Resources Critique of Judgment/Decision Focused Critical Thinking Guides DEVELOPING THE PERSONAL ATTRIBUTES TO THINK CRITICALLY Developing Technical Competencies Developing Interpersonal Competencies PROMOTING HUMAN DIGNITY AND RESPECT ESTABLISHING CARING RELATIONSHIPS PREPARING YOUR ATTENTION AND INTENTION FOR EACH CLINICAL ENCOUNTER ENJOYING THE REWARDS OF MUTUAL EXCHANGE Developing Ethical and Legal Competencies QSEN Competencies Clinical Reasoning, Judgments, and Decision Making Problem Solving TRIAL-AND-ERROR PROBLEM SOLVING SCIENTIFIC PROBLEM SOLVING INTUITIVE PROBLEM SOLVING CRITICAL THINKING: INTUITIVE, LOGICAL, OR BOTH? Creative Thinking Decision Making and Clinical Reasoning THE NURSING PROCESS Historical Perspective Description of the Nursing Process Nursing Process Trends Characteristics of the Nursing Process Systematic Dynamic Interpersonal Outcome Oriented Universally Applicable in Nursing Situations Documenting the Nursing Process Benefits of the Nursing Process Evaluating the Use of the Nursing Process Concept Mapping Promoting Health Literacy IN PATIENTS AND FAMILIES WITH ASTHMA Patient Scenario Nursing Considerations: Tips for Improving Health Literacy REFLECTIVE PRACTICE DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 14 Assessing UNIQUE FOCUS OF NURSING ASSESSMENT ASSESSMENT AND CLINICAL REASONING ASSESSMENT AND INTERPERSONAL COMPETENCE TYPES OF NURSING ASSESSMENTS Initial Assessment Focused Assessment Emergency Assessment Time-Lapsed Assessment Patient-Centered Assessment Method PREPARING FOR DATA COLLECTION Establishing Assessment Priorities Health Orientation Developmental Stage Culture Need for Nursing Structuring the Assessment COLLECTING DATA Sources of Data The Patient The Family and Significant Others The Patient Record MEDICAL HISTORY, PHYSICAL EXAMINATION, AND PROGRESS NOTES CONSULTATIONS REPORTS OF LABORATORY AND OTHER DIAGNOSTIC STUDIES REPORTS OF THERAPIES BY OTHER HEALTH CARE PROFESSIONALS Assessment Technology Other Health Care Professionals Nursing and Other Health Care Literature Methods of Data Collection Nursing History COMPONENTS OF A NURSING HISTORY PATIENT INTERVIEW Physical Assessment Problems Related to Data Collection IDENTIFYING CUES AND MAKING INFERENCES VALIDATING DATA CLUSTERING RELATED DATA AND IDENTIFYING PATTERNS REPORTING AND RECORDING DATA Timing Documentation Privacy, Confidentiality, and Professionalism DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 15 Diagnosing EVOLUTION OF NURSING DIAGNOSES UNIQUE FOCUS OF NURSING DIAGNOSIS Nursing Diagnosis Versus Medical Diagnosis Nursing Diagnosis Versus Collaborative Problem DIAGNOSTIC REASONING AND CLINICAL REASONING DIAGNOSTIC REASONING AND INTERPERSONAL COMPETENCE DATA INTERPRETATION AND ANALYSIS Recognizing Significant Data Recognizing Patterns or Clusters Identifying Strengths and Problems Determining Patient and Family Strengths Determining the Patient’s Problem Areas Determining Problems the Patient Is Likely to Experience Identifying Potential Complications Reaching Conclusions No Problem Possible Problem Actual or Potential Nursing Diagnosis or Problem or Issue Clinical Problem Other Than Nursing Diagnosis Partnering With the Patient and Family FORMULATING AND VALIDATING NURSING DIAGNOSES Terminology for Writing Nursing Diagnoses Types of Nursing Diagnoses Problem-Focused Nursing Diagnoses Risk Nursing Diagnoses Health Promotion Nursing Diagnoses Parts of Nursing Diagnosis Statements Problem Etiology Defining Characteristics Guidelines for Writing Nursing Diagnoses What Is Not a Nursing Diagnosis Validating Nursing Diagnoses Next Steps DOCUMENTING NURSING DIAGNOSES Importance of Nursing Diagnoses in Electronic Health Records NURSING DIAGNOSIS: A CRITIQUE DEVELOPING CRITICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 16 Outcome Identification and Planning UNIQUE FOCUS OF NURSING OUTCOME IDENTIFICATION AND PLANNING Critical Thinking/Clinical Reasoning in Outcome Identification and Planning Interpersonal Competence in Outcome Identification and Planning: Working With Patients and Families COMPREHENSIVE PLANNING Initial Planning Ongoing Planning Discharge Planning ESTABLISHING PRIORITIES Maslow’s Hierarchy of Human Needs Patient Preference Anticipation of Future Problems Critical Thinking/Clinical Reasoning and Establishing Priorities IDENTIFYING AND WRITING OUTCOMES Deriving Outcomes From Nursing Diagnoses Establishing Long-Term Versus Short-Term Outcomes Determining Patient-Centered Outcomes Family Involvement Ensuring Quality Outcomes Using Cognitive, Psychomotor, and Affective Outcomes Identifying Clinical, Functional, and Quality-of-Life Outcomes Identifying Culturally Appropriate Outcomes Identifying Outcomes Supportive of the Total Treatment Plan Writing Patient-Centered Measurable Outcomes Avoiding Common Errors in Outcomes IDENTIFYING NURSING INTERVENTIONS Nurse-Initiated Interventions Identifying and Selecting Appropriate Nurse-Initiated Interventions Individualizing Evidence-Based Interventions Recording Nurse-Initiated Interventions in the Patient Record Physician-Initiated and Collaborative Interventions Structured Care Methodologies Consulting DEVELOPING EVALUATIVE STRATEGIES COMMUNICATING AND RECORDING THE NURSING CARE PLAN Institutional and Facility Care Plans Types of Nursing Care NURSING CARE RELATED TO BASIC HUMAN NEEDS NURSING CARE RELATED TO NURSING DIAGNOSES/PROBLEMS NURSING CARE RELATED TO THE MEDICAL AND INTERDISCIPLINARY CARE PLAN Formats for Care Plans COMPUTERIZED CARE PLANS CONCEPT MAP CARE PLANS CHANGE-OF-SHIFT REPORTS MULTIDISCIPLINARY (COLLABORATIVE) CARE PLANS Student Care Plans Assessing Diagnosing Outcome Identification and Planning Implementing Evaluating PROBLEMS RELATED TO OUTCOME IDENTIFICATION AND PLANNING A FINAL WORD ABOUT STANDARDIZED LANGUAGES AND HOLISTIC, PERSON-CENTERED CARE DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 17 Implementing UNIQUE FOCUS OF NURSING IMPLEMENTATION The Nursing Interventions Taxonomy Structure Care Coordination, Continuity, and the Nurse CRITICAL THINKING/CLINICAL REASONING AND IMPLEMENTING IMPLEMENTING AND INTERPERSONAL COMPETENCE TYPES OF NURSING INTERVENTIONS Nursing Interventions Classification Independent and Collaborative Interventions Protocols and Standing Orders IMPLEMENTING THE CARE PLAN Reassessing the Patient and Reviewing the Plan of Care Using Patient Boards or Whiteboards Clarifying Prerequisite Nursing Competencies Planning Ahead and Organizing Resources Patient and Patient Visitors Equipment Environment Personnel Anticipating Unexpected Outcomes and Situations Ensuring Quality and Patient Safety: Preventing Errors and Omissions Promoting Self-Care: Teaching, Counseling, and Advocacy Assisting Patients to Meet Health Outcomes Patient Variables DEVELOPMENTAL STAGE PSYCHOSOCIAL BACKGROUND AND CULTURE Nurse Variables Resources Current Standards of Care Research Findings Ethical and Legal Guides to Practice CONTINUING DATA COLLECTION AND RISK MANAGEMENT DOCUMENTING NURSING CARE WHEN A PATIENT DOES NOT COOPERATE WITH THE PLAN OF CARE DELEGATING NURSING CARE Delegation and the Student Nurse GUIDE FOR STUDENTS Organizing Care Nursing Oneself DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 18 Evaluating UNIQUE FOCUS OF NURSING EVALUATION CRITICAL THINKING/CLINICAL REASONING AND EVALUATING Identifying Evaluative Criteria and Standards Collecting Evaluative Data Types of Outcomes Time Criteria Interpreting and Summarizing Findings Documenting Your Judgment Modifying the Care Plan EVALUATING QUALITY CARE Performance Improvement in Everyday Clinical Practice Establishing and Sustaining Healthy Work Environments Evaluative Programs Quality Assurance From Quality Assurance to Quality Improvement Patient Satisfaction Nursing’s Patient Safety and Quality Initiative Concurrent Versus Retrospective Evaluation DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 19 Documenting and Reporting DOCUMENTING CARE Guidelines for Effective Documentation Privacy and Confidentiality What Information Is Confidential? Health Information Privacy Facility Policies Delegating Documentation Purposes of Patient Records Communication Diagnostic and Therapeutic Orders VERBAL ORDERS Care Planning Quality Process and Performance Improvement Research Decision Analysis Education Credentialing, Regulation, and Legislation Legal Documentation Reimbursement Historical Documentation Methods of Documentation Computerized Documentation and Electronic Health Records PERSONAL HEALTH RECORDS HEALTH INFORMATION EXCHANGE Source-Oriented Records Problem-Oriented Medical Records PIE Charting: Problem, Intervention, Evaluation Focus Charting Charting by Exception Case Management Model COLLABORATIVE PATHWAYS OCCURRENCE CHARTING Formats for Nursing Documentation Initial Nursing Assessment Care Plan Patient Care Summary Critical/Collaborative Pathways Progress Notes Flow Sheets and Graphic Records Medication Administration Records (MARs) Acuity Records Discharge and Transfer Summary Home Health Care Documentation Long-Term Care Documentation REPORTING CARE Change-of-Shift/Handoff Reports Telephone/Telemedicine Reports Transfer and Discharge Reports Reports to Family Members and Significant Others Incident Reports CONFERRING ABOUT CARE Consultations and Referrals Nursing and Interdisciplinary Team Care Conferences Nursing Care Rounds Purposeful Rounding DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 20 Nursing Informatics HISTORY OF NURSING INFORMATICS NURSING INFORMATICS DEFINED NURSING INFORMATICS EDUCATION NURSING INFORMATICS PRACTICE THE SYSTEM DEVELOPMENT LIFECYCLE Analyze and Plan Design Test Train Implement Maintain Evaluate IMPORTANT INFORMATICS CONCEPTS TO UNDERSTAND System Usability System Optimization Standard Terminologies Interoperability Security and Privacy of Electronic Data EMERGING AREAS IN THE FIELD OF INFORMATICS Patient Portals Health Care Analytics Data Visualization Predictive Analytics Big Data Example: Using Analytics and Big Data to Support Population Health Telehealth and Mobile Technologies Genetics and Genomics: Precision Medicine DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 21 Developmental Concepts PRINC