《护理学导论》英文讲义 第十章护理程序Word格式.docx

《护理学导论》英文讲义 第十章护理程序Word格式.docx

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3.Definethemajorcharacteristicsofnursingprocess

4.Stateconceptofassessing

5.Differentiateobjectivedataandsubjectivedata

6.Identifysourcesofdata

7.Applythemethodscorrectlyindatacollection

KeyPoints

1.Conceptofnursingprocess

2.Steps（phases）ofnursingprocess

3.Characteristicsofnursingprocess

4.Conceptofassessing

DifficultPoints

1.Typesofdata

2.Sourcesofdata

3.Applythemethodscorrectlyindatacollection

Contents

1.Historicalperspective

In1955,LydiaHallintroducednursingprocess

1960-1973,nursingtheoristshadbeenverifyingstepsofnursingprocess

1973,ANApublishedthe“StandardsofNursingPractice”,thefivenursingprocessmodelisdescribedinstandardsofnursingpractice.

1980,furthercommitmentbytheANAtothefive-stepnursingprocessmodelwasdocumentedinthe1980“NursingandSocialPolicyStatement”,thismadethismodelthestandardforprofessionalnursingpracticein1991,RevisionoftheANA“StandardsofclinicalNursingPractice”continuestousethefive-stepmodel.

2.Descriptionofnursingprocess

Asystematicmethodthatdirectsthenursingandclienttogether

1）Determinetheneedfornursingcare

2）Planandimplementthecare

3）Evaluatetheresults

4）Five-stepnursingprocessmodel

2.1Assessing

establishesthedatabase

continuouslyupdatesthedatabase

validatesdata

communicatesdata

2.2Diagnosing

interpretsandanalyzesclientdata

identifiesclientstrengths,healthproblem

formulates,validatesnursingdiagnoses

developsaprioritizedlistnursingdiagnose

2.3Planning

establishespriorities

writesexpectedoutcomes

develops,selectsnursinginterventions

communicatestheplanofcare

2.4Implementing

carriesouttheplanofcare

continuescollectingdataandmodifiestheplan

documentscare

2.5Evaluating

measuresdesiredoutcomes

identifiesfactorscontributingtofailure

modifiestheplanofcare

Thefivestepsinnursingprocessareinterrelated,eachofthefivestepsdependsontheaccuracyofthestepsprecedingit.Theprocessprovidesaframeworkthatenablethenursetoprovideeffectivecaretotheclients.

3.Characteristicsofnursingprocess

3.1Systematic

Eachstepdependsontheaccuracyofthepreviousstepandinfluencesthenextstep.Thenursingprocessdirectseachstepofnursingcareinasequentialmanner.

3.2Interpersonal

Ensurethatnursesareclient-centeredratherthantasked-centered

3.3Goal-oriented

Offerameansfornursesandclientstoworktogethertoidentifyspecifichealthgoalswhicharemostimportanttotheclient:

improvingtheiroralhygiene,livewithpain,recoverfromanacutemedicalillness,preventionrecurrence,orpreparefordeath

4.Assessing

4.1Definition

Aprocessofgathering,verifying,andcommunicatingdataaboutaclient

4.2Purpose

4.2.2toobtainrelevantinformationaboutthestrengthsandneedsofclients

4.2.3toestablishadatabaseaboutclients:

pt,familypatternsofhealthandillness,deviationfromnormal,strengths,copingabilitiesandriskfactorsforhealthproblem

4.2.4toestablishadatabaseforplanningcare

4.3Typesofdata

4.3.1Subjectivedata

Client’sperceptionsabouttheirhealthproblems

4.3.2Objectivedata

Observationsormeasurementsmadebythedatacollectorbasedonanacceptedstandard

4.4Characteristicsofdata

4.4.1Complete

Alltheclientdataneeded

4.4.2Factualandaccurate

Recordingtheclient’sbehaviors,factually

4.4.3Relevant

Whatandhow:

whattypeofdataandhowmuchdatatocollectforeachclient.

4.5Sourcesofdata

4.5.1Primary

Client

.Healthcareneeds

·

Lifestyle

Presentandpastillness

Perceptionofsymptoms

Changesinactivities

4.5.2Secondary

.Nurse’sownObservations

.Family,members,friends,Supportpeople

4.5.3Tertiary

Clientrecord

.healthrecord:

age,sex,occupation,religiouspreference,financialstatus

medicalhistory

physicalexamination

progressnotes

consultations

.diagnosticstudy:

bloodanalysis,urineanalysis,radiologicalexamination,stoolanalysis,sputumanalysis,andothers:

electrocardiogramECG,stresstest,tuberculosisTBskintest

Otherhealthcareprofessionals

.Literature:

consultthenursingandrelatedliteratureonspecifichealthproblems.

4.5Methodsofdatacollection

4.5.1Observation

useofthefivephysicalsenses（hearing,seeing,tactile触觉,smell嗅觉,taste,味觉）togatherdata

client’scurrentresponsetosituation.

client’scurrentabilitytomanagehiscare,needforadditionalinformationornursingassistance?

theimmediateenvironment

thelargerenvironment

4.5.2Interview

Apatternofplannedcommunicationforaspecificpurposeandfocusedonaspecificcontentarea

4.5.3Nursinghealthhistory

reasonforseekinghealthcare:

goalsofcare,expectationoftheservicesandcaredelivered,andexpectationofthehealthcaresystem

presentillnessorhealthconcern:

onset,symptoms,natureofsymptoms,duration,precipitatingfactors,reliefmeasures,andweightlossorgain

pasthealthhistory，habits,prescribedandself-prescribedmedications,workhabits,relaxationactivities,andsleep,exercise,andeatingornutritionalpatterns.

familyhistory:

healthstatusoftheimmediatefamilyandlivingrelatives.

environmentalhistory:

hazards,pollutants,andphysicalsafety.

psychosocialandculturalhistory:

reviewofsystem:

head-totoereviewofallmajorbodysystems,aswellastheclient’sknowledgeofandcompliancewithhealthcare.

expectationsofcare

abilityandwillingnesstoparticipateinthecare

personalresourcesanddeficits

Initiatingofaninterview

Thenurseinitiatestheinterviewbystatinghisorhernameandstatus,identifyingthepurposeoftheinterview,andclarifyingtherolesofnurseandclient.

4.5.3Physicalassessment

Takingofvitalsignsandothermeasurementsandtheexaminationofallbodypartsusingthetechniquesofinspection,palpation,percussion,andauscultation.

Generalsurvey

measuringheight,weight,andvitalsigns

head-to-toeexaminationofthebodysystems

4.6Sorting,validatingdata

Organizestheinformationintomeaningfulclustersbyusing

System-orientedformat

Functionalhealthpatternformat

focusesattentiononfunctionsneedingsupportandassistanceforrecovery

confirmingorverifyingsoastokeepdataasfreefromerror,bias,andmisinterpretationaspossible

4.7Datadocumentation

•Essentialfortworeasons

•alldatapertinenttoclientstatusareincluded

•legalandprofessionalresponsibility

•Datashouldbesummarizedandenteredintocomputerorrecordedinink

•usingthedesignatedagencyforms

•Datashouldbewrittenlegibly,goodgrammarUsestandardmedicalabbreviations

Criticalthinkingexercise

Workingwithanotherstudent,togetherinterviewclientsinbothhomeandinstitutionalsettings.Makealistoftheobjectiveandsubjectivedatayougatheroneachclientinterviewedandcompareyourdatalists.Explorethereasonsforthedifferencesyoudiscoveramongclients,betweenhomeandresidentialsettings,andbetweenwhatyouandyourpartnerdecidetorecord.

Section2NursingDiagnosis

Objectives:

1.Afterstudyingthissession,thestudentsshouldbeableto

2.Definetheconceptofnursingdiagnosis.

3.Definetheconceptofcollaborativeproblems

4.DescribeimportanceandpurposesofND

5.DescribeandidentifycategoriesofND

6.Stateformatforwritingdiagnosticstatements

Keypoints

1.Conceptofnursingdiagnosis

2.Conceptofcollaborativeproblems

3.PurposesofND

4.Difficultpoints

1.Revision

Thediscussionofnursingasascienceandaprofessiondescribednursingashavingindependent,interdependent,anddependentfunctions.Asnursesinterpretandanalyzeclientdata,nurseidentifieswhatitisabouttheclientthatisnurse’suniqueconcern,nursingdiagnosesarethereforewrittentodescribeclientproblemsthatnursescantreatindependently;

theymayidentifyhealthproblemsthatarebettertreatedbyphysicians（medicaldiagnoses）orbynursesworkingwithotherhealthcareprofessionals（collaborativeproblems）.

Thediscussionofnursingdiagnosishasfocusedprimarilyonthoseproblemsthatarewithinthedomainofnurse’sindependentfunction.Theseareproblemsforwhichnursescanlegallydeterminetheactionstoprevent,solve,orrelievetheproblems.

Manyofclientshavediagnosedmedicalproblems（disease）.Thesesameclientshavealikehoodofdevelopingdifficultiesorpotentialcomplicationsrelatedtoadiseaseortomedicalorsurgicalinterventionsusedtotreatthedisease.Otherclientsareatriskfordevelopingmedicalcomplicationsfromdiagnostictests,whetherornottheyhaveactualdisease.Theseactualorpotentialproblemsareoutsidethenurse’sindependentfunction,,aredesignatedas“collaborativeproblems”.

Diagnosing:

isphase2ofthenursingprocess.Thisphaseincludesanalyzingdata,formulatingnursingdiagnoses,andidentifyingstrengthsandproblems/needsofclients.

Analyzingdata:

focalpointsareboththeclients’strengthsandneeds

Nursingdiagnoses:

summarizetheclients’

Analyzing:

isanimportantmentalactivityt