护理程序英语写作范例文档格式.docx
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E_les:
B/P100/62
Voided200ccdarkambercoloredurine
SubjectiveData
Informationgivenverballybythepatient.
Iitchallover.
Mystomachaches.
Imafraidofgoingtosurgerytomorrow.
MethodsofCollectingData
1.Observation
2.Interview
a.Formal
b.Informa
c.E_amination
AnalysisandInterpretationofData
1.Continuallyupdateandrevise
2.Clusterdata
3.Identifynursingdiagnoses
NursingDiagnosisAstatementofanactualorpotentialresponsetoahealthproblemthatthenurseispetentandlicensedtotreat.
Actual:
asituationthate_istsinthehereandnow.
-alterationinfort
-ineffectivebreathingpattern
-impairedskinintegrity
Potential:
asituationwhichmaycausedifficultyinthefuture.
-highriskforinjury
-highriskforsleeppatterndisturbance
-highriskforimpairedskinintegrity
NursingDiagnosisStatementContainstwoparts:
1.Thestatementofthepatientproblem
2.Thecontributingfactorsorprobablecausesoftheproblem-theetiology.
Thetwopartsarejoinedbythewordsrelatedto
1.Ineffectivebreathingpattern(problem)relatedtochestpain(etiology)。
2.Highriskforinjury(problem)relatedtopoorvisionanddecreasedmobility(etiology)。
3.Alterationinnutrition(problem)relatedtonausea(etiology)。
Thingstoremember:
1.Onlyonenursingdiagnosisperpatientproblem.
2.Eachnursingdiagnosiscanhavemorethanoneetiology.
3.Thenursingdiagnosisisnotamedicaldiagnosis-avoidusingamedicaldiagnosisaspartoftheetiology.
4.Nursingdiagnosesidentifyhealthproblemsandenableaplanofcaretobedevelopedtoachieveama_imallevelofwellness.
5.UsetheNANDAlisttohelpyouformulateyournursingdiagnosis.
PlanningThephaseofthenursingprocessinwhichyoudevelopaplanofcareanddeterminehowyouaregoingtosolve,lessenorminimizetheeffectsofthepatientsproblems.
Thereare4stepsinthisphase.
Step1:
SettingPriorities
1.Determinewhichproblemposesthegreatestthreattothepatientswell-being.
-Thisbees
-Continuetoprioritizeinthisway.
2.Findoutwhichproblemsthepatientfeelsaremostimportant.
Step2:
WritingGoals
1.Agoalisaspecificandmeasurableobjectivedesignedtoreflectthepatientshighestlevelofwellnessandindependenceinfunction.
2.Thegoalisderivedfromthefirstpartofthenursingdiagnosisstatement.
3.Thereare2categoriesofgoals:
a.Shortterm-canbemetfairlyquickly(hoursordays)
b.Longterm-coveralongertimespan
GuidelinesforGoalWriting
1.Writegoalsinobservableormeasurableterms.
2.Writegoalsintermsofpatientoutesnotnursingactions.
3.Keepgoalsshortandspecific.
4.Designateatimeforachievementofthegoal.
E_lesofGoals
Thepatientwillbefreeofinfectionthroughouthospitalization.
Thepatientslungswillremainclearpostoperatively.
Thepatientsskinwillbehealedby1/31.
Step3:
DevelopingtheE_pectedOutes
E_pectedOutesdefinewhenapatientgoalhasbeenmetandassistinevaluatingthee_tenttowhichthenursingdiagnosishasbeenresolved.
Theyarestatedinobservableormeasurableterms.
Functions:
1.Provideadirectionfornursingactivities.
2.Indicatewhatshouldoccurduringthetimespanindicatedinthegoal.
3.Usedtoevaluatetheeffectivenessofthenursinginterventions.
E_le
Goal:
Thepatientslungswillremainclearpostoperatively.
E_pectedOutes:
-thesputumwillremainwhite.
-thepatientwillremainafebrile.
-thelungswillbecleartoauscultation.
Step4:
PlanningNursingActions
NursingActionsarethosethingsthenurseplanstodotohelpthepatientachieveagoal.
NursingActionsarederivedfromtheetiologyofthenursingdiagnosis.
Guidelinesforselectingnursingactions
1.Besuretheactionsfocusontheetiologyofthenursingdiagnosis.
2.Mustbesafeforthepatient.
3.Mustbecongruentwithothertherapies.
4.Shouldbebasedonprinciplesofnursinganddisciplinesrelatedtonursing.
5.Mustbebasedonappropriaterationale.
6.Eachnursingdiagnosisshouldhaveitsownsetofnursingactions.
7.Chooseactionsmostlikelytodevelopthebehaviorinthegoal.
8.Mustberealistic.
9.Usethepatientasasourceforchoosingnursingactions.
TypesofNursingActions
1.Dependent
-anursingactionbasedontheinstructionofanotherprofessional
2.Independent
-requiresnosupervisionordirectionfromothers
3.Interdependent
-actionscarriedoutbythenurseincollaborationwithanotherhealthcareprofessional
QuestionsNursingActionsShouldAnswer:
1.Whatistheaction
2.Whenshouldtheactionbeimplemented
3.Howshouldtheactionbeperformed
4.Whoshouldbeinvolvedincarryingouttheaction
ImplementationPhase1.Validatinganddocumentingcare.
2.Givingnursingcare.
3.Continuingdatacollection.
EvaluationPhase1.Evaluategoalachievement:
a.evaluateonlythepatientsabilitytoperformthebehaviorinthegoal-dontevaluatethenursingactions.
2.Threealternatives:
a.goalmet
b.goalpartiallymet
c.goalnotmet
3.Includeastatementofwherethepatientisnowintermsofthee_pectedoutes.
4.Whenthegoalispartiallymetornotmet,thenthecareplanmustbereassessed.
5.Possibleoutes:
-prioritiesmaychangeandproblemsmayhavetobedealtwith.
-newdatamayindicatethereisanewproblemtobedealtwith.
-thegoalmaybemetandtheproblemnolongere_ists.
-thegoalmaybemet,buttheproblemstille_ists.Mayrequirechanginggoal,e_pectedoutesandnursingactions.
-ifthegoalwasnotmet,thenurseneedstocorrecttheunsuccessfulplan.
CriticalThinkingDefinition:
anattitudeandareasoningprocessinvolvingintellectualskills-apurposefulmentalactivityinwhichideasareproducedandevaluatedandjudgmentsaremade.
CharacteristicsofCriticalThinking
1.Conceptualization
2.RationalandReasonable
3.Reflective
4.Anattitudeofinquiry
5.AutonomousThinking
6.CreativeThinking
7.FairThinking
8.Decidingwhattobelieveordo