《护理学导论》英文讲义 第十章护理程序Word格式.docx

1、3. Define the major characteristics of nursing process4. State concept of assessing5. Differentiate objective data and subjective data6. Identify sources of data7. Apply the methods correctly in data collectionKey Points1.Concept of nursing process2.Steps（phases） of nursing process3.Characteristics

2、of nursing process4. Concept of assessingDifficult Points1. Types of data2. Sources of data3. Apply the methods correctly in data collectionContents1. Historical perspectiveIn 1955, Lydia Hall introduced nursing process 1960-1973, nursing theorists had been verifying steps of nursing process 1973, A

3、NA published the “Standards of Nursing Practice”, the five nursing process model is described in standards of nursing practice. 1980, further commitment by the ANA to the five-step nursing process model was documented in the 1980 “Nursing and Social Policy Statement”, this made this model the standa

4、rd for professional nursing practice in 1991, Revision of the ANA “Standards of clinical Nursing Practice”continues to use the five-step model.2. Description of nursing processA systematic method that directs the nursing and client together 1） Determine the need for nursing care 2） Plan and implemen

5、t the care 3） Evaluate the results4） Five-step nursing process model 2.1 Assessing establishes the data base continuously updates the data base validates data communicates data 2.2 Diagnosing interprets and analyzes client data identifies client strengths, health problem formulates, validates nursin

6、g diagnoses develops a prioritized list nursing diagnose 2.3 Planning establishes priorities writes expected outcomes develops, selects nursing interventions communicates the plan of care 2.4 Implementing carries out the plan of care continues collecting data and modifies the plan documents care 2.5

7、 Evaluating measures desired outcomes identifies factors contributing to failure modifies the plan of care The five steps in nursing process are interrelated, each of the five steps depends on the accuracy of the steps preceding it. The process provides a framework that enable the nurse to provide e

8、ffective care to the clients.3. Characteristics of nursing process3.1 Systematic Each step depends on the accuracy of the previous step and influences the next step. The nursing process directs each step of nursing care in a sequential manner.3.2 Interpersonal Ensure that nurses are client-centered

9、rather than tasked-centered3.3 Goal-oriented Offer a means for nurses and clients to work together to identify specific health goals which are most important to the client: improving their oral hygiene, live with pain, recover from an acute medical illness, prevention recurrence, or prepare for deat

10、h 4. Assessing4.1 Definition A process of gathering, verifying, and communicating data about a client4.2 Purpose4.2.2 to obtain relevant information about the strengths and needs of clients 4.2.3 to establish a data base about clients: pt, family patterns of health and illness, deviation from normal

11、, strengths, coping abilities and risk factors for health problem4.2.4 to establish a data base for planning care4.3 Types of data4.3.1 Subjective data Clients perceptions about their health problems 4.3.2 Objective data Observations or measurements made by the data collector based on an accepted st

12、andard 4.4 Characteristics of data4.4.1 Complete All the client data needed 4.4.2 Factual and accurateRecording the clients behaviors, factually4.4.3 RelevantWhat and how: what type of data and how much data to collect for each client.4.5 Sources of data4.5.1 PrimaryClient. Health care needs Lifesty

13、le Present and past illness Perception of symptoms Changes in activities4.5.2 Secondary .Nurses own Observations .Family, members, friends, Support people4.5.3 TertiaryClient record. health record: age, sex, occupation, religious preference, financial status medical history physical examination prog

14、ress notes consultations.diagnostic study: blood analysis, urine analysis, radiological examination, stool analysis, sputum analysis, and others: electrocardiogram ECG, stress test, tuberculosis TB skin testOther healthcare professionals.Literature: consult the nursing and related literature on spec

15、ific health problems. 4.5 Methods of data collection4.5.1 Observation use of the five physical senses （hearing, seeing, tactile触觉, smell嗅觉, taste,味觉 ） to gather data clients current response to situation. clients current ability to manage his care, need for additional information or nursing assistan

16、ce?the immediate environment the larger environment4.5.2 InterviewA pattern of planned communication for a specific purpose and focused on a specific content area4.5.3 Nursing health history reason for seeking health care: goals of care, expectation of the services and care delivered, and expectatio

17、n of the health care system present illness or health concern: onset, symptoms, nature of symptoms, duration, precipitating factors, relief measures, and weight loss or gain past health history，habits, prescribed and self-prescribed medications, work habits, relaxation activities, and sleep, exercis

18、e, and eating or nutritional patterns. family history: health status of the immediate family and living relatives.environmental history: hazards, pollutants, and physical safety.psychosocial and cultural history: review of system: head-to toe review of all major body systems, as well as the clients

19、knowledge of and compliance with health care. expectations of care ability and willingness to participate in the carepersonal resources and deficits Initiating of an interviewThe nurse initiates the interview by stating his or her name and status, identifying the purpose of the interview, and clarif

20、ying the roles of nurse and client. 4.5.3 Physical assessment Taking of vital signs and other measurements and the examination of all body parts using the techniques of inspection, palpation, percussion, and auscultation. General survey measuring height, weight, and vital signs head-to-toe examinati

21、on of the body systems4.6 Sorting, validating dataOrganizes the information into meaningful clusters by using System-oriented format Functional health pattern formatfocuses attention on functions needing support and assistance for recoveryconfirming or verifying so as to keep data as free from error

22、, bias, and misinterpretation as possible4.7 Data documentation Essential for two reasons all data pertinent to client status are included legal and professional responsibility Data should be summarized and entered into computer or recorded in ink using the designated agency forms Data should be wri

23、tten legibly, good grammar Use standard medical abbreviationsCritical thinking exerciseWorking with another student, together interview clients in both home and institutional settings. Make a list of the objective and subjective data you gather on each client interviewed and compare your data lists.

24、 Explore the reasons for the differences you discover among clients, between home and residential settings, and between what you and your partner decide to record.Section 2 Nursing DiagnosisObjectives:1. After studying this session, the students should be able to2. Define the concept of nursing diag

25、nosis.3. Define the concept of collaborative problems4. Describe importance and purposes of ND5. Describe and identify categories of ND 6. State format for writing diagnostic statements Key points1. Concept of nursing diagnosis2. Concept of collaborative problems3. Purposes of ND4. Difficult points1

26、. RevisionThe discussion of nursing as a science and a profession described nursing as having independent, interdependent, and dependent functions. As nurses interpret and analyze client data, nurse identifies what it is about the client that is nurses unique concern, nursing diagnoses are therefore

27、 written to describe client problems that nurses can treat independently; they may identify health problems that are better treated by physicians （medical diagnoses） or by nurses working with other healthcare professionals（ collaborative problems）. The discussion of nursing diagnosis has focused pri

28、marily on those problems that are within the domain of nurses independent function. These are problems for which nurses can legally determine the actions to prevent, solve, or relieve the problems.Many of clients have diagnosed medical problems（disease）. These same clients have a likehood of develop

29、ing difficulties or potential complications related to a disease or to medical or surgical interventions used to treat the disease. Other clients are at risk for developing medical complications from diagnostic tests, whether or not they have actual disease. These actual or potential problems are ou

30、tside the nurses independent function, , are designated as “collaborative problems”.Diagnosing: is phase 2 of the nursing process. This phase includes analyzing data, formulating nursing diagnoses, and identifying strengths and problems/needs of clients.Analyzing data: focal points are both the clients strengths and needsNursing diagnoses: summarize the clientsAnalyzing: is an important mental activity t