护理程序英语写作范例文档格式.docx

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