Nurse's Clinical Pocket Manual: Nursing Diagnoses, Care Planning, and Documentation. Moorhouse M, Doenges M, Philadelphia, FA Davis, 1 990, 477 pages, $22.95.
Written by two clinical nurse specialists, this informative clinical pocket manual focuses on nursing care plan formulation, documentation, and charting tips. The manual is divided into three sections.
The first chapter presents a concise overview of 1 1 nursing theories in terms of their major focus, goal of nursing, and nursing process format. The circular nature of the nursing process is outlined in Chapter 2, and several of the nursing diagnoses contain additions to clarify and enhance their use. An interesting aspect of Chapter 3, which addresses data collection, is the grouping of nursing diagnoses into 13 divisions to represent human responses and needs rather than specific "systems." The final two chapters of this section give a concise overview of a range of salient areas pertaining to the construction of care plans and documentation.
The second section attempts to put theory into practice, and seven illustrative care plans are described for a variety of situations. For each care plan, a short description of the situation is given, followed by sections on initial tests and treatment, admitting physician's orders, nursing history and assessment data for the 13 human response areas, nursing diagnosis and specific goals for each, nursing actions and rationale, and discharge considerations that emphasize assessment of patient resources and anticipated areas requiring assistance.
The third section provides selected nursing diagnostic statements for approximately 300 disorders and health problems, and thus affords ready access to priority needs for persons suffering from a particular condition (eg, Alzheimer's disease). In addition, this section is further codified to identify each health problem by nursing specialty areas.
Three salient features of this book are indicative of its usefulness for registered nurses, nursing students, and nurse educators: the arrangement of nursing diagnoses into a nursing model; the application of data to a broad range of nursing practice situations, including long-term care; and a format that would be useful for students as a review, and for nursing instructors in developing examinations.