护理程序英语写作范例文档格式.docx

1、E_les：B/P 100/62Voided 200cc dark amber colored urineSubjective DataInformation given verbally by the patient.I itch all over.My stomach aches.Im afraid of going to surgery tomorrow.Methods of Collecting Data1. Observation2. Interviewa. Formalb. Informac. E_aminationAnalysis and Interpretation of Da

2、ta1. Continually update and revise2. Cluster data3. Identify nursing diagnosesNursing Diagnosis A statement of an actual or potential response to a health problem that the nurse is petent and licensed to treat.Actual： a situation that e_ists in the here and now.- alteration in fort- ineffective brea

3、thing pattern- impaired skin integrityPotential： a situation which may cause difficulty in the future.- high risk for injury- high risk for sleep pattern disturbance- high risk for impaired skin integrityNursing Diagnosis Statement Contains two parts：1. The statement of the patient problem2. The con

4、tributing factors or probable causes of the problem - the etiology.The two parts are joined by the words related to1. Ineffective breathing pattern （problem） related to chest pain （etiology）。2. High risk for injury （problem） related to poor vision and decreased mobility （etiology）。3. Alteration in n

5、utrition （problem） related to nausea （etiology）。Things to remember：1. Only one nursing diagnosis per patient problem.2. Each nursing diagnosis can have more than one etiology.3. The nursing diagnosis is not a medical diagnosis - avoid using a medical diagnosis as part of the etiology.4. Nursing diag

6、noses identify health problems and enable a plan of care to be developed to achieve a ma_imal level of wellness.5. Use the NANDA list to help you formulate your nursing diagnosis.Planning The phase of the nursing process in which you develop a plan of care and determine how you are going to solve， l

7、essen or minimize the effects of the patients problems.There are 4 steps in this phase.Step 1： Setting Priorities1. Determine which problem poses the greatest threat to the patients well-being.- This bees- Continue to prioritize in this way.2. Find out which problems the patient feels are most impor

8、tant.Step 2： Writing Goals1. A goal is a specific and measurable objective designed to reflect the patients highest level of wellness and independence in function.2. The goal is derived from the first part of the nursing diagnosis statement.3. There are 2 categories of goals：a. Short term - can be m

9、et fairly quickly （hours or days）b. Long term - cover a longer time spanGuidelines for Goal Writing1. Write goals in observable or measurable terms.2. Write goals in terms of patient outes not nursing actions.3. Keep goals short and specific.4. Designate a time for achievement of the goal.E_les of G

10、oalsThe patient will be free of infection throughout hospitalization.The patients lungs will remain clear postoperatively.The patients skin will be healed by 1/31.Step 3： Developing the E_pected OutesE_pected Outes define when a patient goal has been met and assist in evaluating the e_tent to which

11、the nursing diagnosis has been resolved.They are stated in observable or measurable terms.Functions：1. Provide a direction for nursing activities.2. Indicate what should occur during the time span indicated in the goal.3. Used to evaluate the effectiveness of the nursing interventions.E_leGoal： The

12、patients lungs will remain clear postoperatively.E_pected Outes：- the sputum will remain white.- the patient will remain afebrile.- the lungs will be clear to auscultation.Step 4： Planning Nursing ActionsNursing Actions are those things the nurse plans to do to help the patient achieve a goal.Nursin

13、g Actions are derived from the etiology of the nursing diagnosis.Guidelines for selecting nursing actions1. Be sure the actions focus on the etiology of the nursing diagnosis.2. Must be safe for the patient.3. Must be congruent with other therapies.4. Should be based on principles of nursing and dis

14、ciplines related to nursing.5. Must be based on appropriate rationale.6. Each nursing diagnosis should have its own set of nursing actions.7. Choose actions most likely to develop the behavior in the goal.8. Must be realistic.9. Use the patient as a source for choosing nursing actions.Types of Nursi

15、ng Actions1. Dependent- a nursing action based on the instruction of another professional2. Independent- requires no supervision or direction from others3. Interdependent- actions carried out by the nurse in collaboration with another health care professionalQuestions Nursing Actions Should Answer：1

16、. What is the action2. When should the action be implemented3. How should the action be performed4. Who should be involved in carrying out the actionImplementation Phase 1. Validating and documenting care.2. Giving nursing care.3. Continuing data collection.Evaluation Phase 1. Evaluate goal achievem

17、ent：a. evaluate only the patients ability to perform the behavior in the goal - dont evaluate the nursing actions.2. Three alternatives：a. goal metb. goal partially metc. goal not met3. Include a statement of where the patient is now in terms of the e_pected outes.4. When the goal is partially met o

18、r not met， then the care plan must be reassessed.5. Possible outes：- priorities may change and problems may have to be dealt with.- new data may indicate there is a new problem to be dealt with.- the goal may be met and the problem no longer e_ists.- the goal may be met， but the problem still e_ists

19、. May require changing goal， e_pected outes and nursing actions.- if the goal was not met， the nurse needs to correct the unsuccessful plan.Critical Thinking Definition： an attitude and a reasoning process involving intellectual skills - a purposeful mental activity in which ideas are produced and evaluated and judgments are made.Characteristics of Critical Thinking1. Conceptualization2. Rational and Reasonable3. Reflective4. An attitude of inquiry5. Autonomous Thinking6. Creative Thinking7. Fair Thinking8. Deciding what to believe or do