Table of Contents

1. Propelling the Delivery of Health Care Into the 21st Century. Delivering Consistent, Competent Care. Measuring Performance Improvement. Malpractice: Failure to Implement Professional Standards. 2. The Relationship of Critical Thinking, Problem Solving, Nursing Process, and Decision Making. Critical Thinking. Problem Solving and Nursing Process. Decision Making. 3. Assessment and Reassessment. JCAHO Standard on Assessment. Interdisciplinary Assessment. Confidentiality of Information. Integrating Models. Phase One: Assessment/Reassessment. Data Collection. Data Validation. Organizing (Grouping, Clustering) Data. Reassessment of Clients. Reporting and Recording the Assessment and Reassessment Data. 4. Diagnosis: Identifying a Problem or Deficit. Background and Rationale for Nursing Diagnoses. Definitions of Nursing Diagnoses. Components of a Nursing Diagnosis. Writing a Nursing Diagnosis in the Medical Record. Medical Diagnoses. 5. Plan of Care and Outcome Identification. Components of Plans and Outcome Identification. 6. Implementation. Components of Implementation. Types of Charting. Writing Legally Sound Nurses' Notes. Computer Charting. Guidelines for Accurate Charting. 7. Evaluation of Outcomes. Components of Evaluation. 8. Case Study Using Functional Health Patterns. Case Study #1, James Hill. 9. Case Study Using a Body Systems Approach. Case Study #2, Judith Smith. Appendices. NANDA's Taxonomy 1, revised 1994. NANDA's 1994 List of Approved Nursing Diagnoses, Definitions, Related Factors, and Defining Characteristics. Nursing Diagnoses Grouped by Gordon's 11 Functional Health Patterns. Nursing Diagnoses Grouped by a Modified Body Systems Approach. List of Measurable Verbs and Criteria. List of Normal Values: Blood, Urine, Stool. Vital Signs, Height, and Weight for Adults. Normal Values and Standards: Fluid Balance in an Adult. Medications. Nonpharmacologic Pain Management: Relaxation Exercises. ANA Standards of Clinical Nursing Practice (1991). Interdisciplinary Plan of Care. Vaginal Delivery Critical Pathway: Infant. Vaginal Delivery Critical Pathway: Mother. Cesarean Delivery Critical Pathway: Infant. Cesarean Delivery Critical Pathway: Mother. Glossary. References. Index.