护理程序英语写作范例
护理程序英语写作范例
对护理的定义，由于历史背景、社会发展、环境和文化以及教育等因素的不同，人们有不同的解释和说明。接下来小编为大家整理了护理程序英语写作范例，希望对你有帮助哦!
学习啦在线学习网 A systematic method of providing nursing care. It provides a framework for planning and implementing nursing care.
学习啦在线学习网 Components 1. Assessment (ends with the formulation of a nursing diagnosis)
2. Planning
3. Implementation
4. Evaluation
Assessment Definition：
The process of gathering， verifying and communicating data about a patient. Data is gathered from a variety of sources and is the basis for actions and decisions.
学习啦在线学习网 Data Collection
学习啦在线学习网 1. Begins upon admission
2. Is a continual action throughout each phase of the nursing process
3. Data is classified as either objective or subjective
Objective Data
Factual data observed by the nurse. No conclusions or interpretations are made.
Examples：
学习啦在线学习网 B/P 100/62
学习啦在线学习网 Voided 200cc dark amber colored urine
Subjective Data
Information given verbally by the patient.
Examples：
"I itch all over."
"My stomach aches."
"I'm afraid of going to surgery tomorrow."
Methods of Collecting Data
1. Observation
学习啦在线学习网 2. Interview
a. Formal
b. Informa
c. Examination
Analysis and Interpretation of Data
1. Continually update and revise
学习啦在线学习网 2. Cluster data
学习啦在线学习网 3. Identify nursing diagnoses
Nursing Diagnosis A statement of an actual or potential response to a health problem that the nurse is competent and licensed to treat.
学习啦在线学习网 Actual： a situation that exists in the here and now.
- alteration in comfort
- ineffective breathing pattern
- impaired skin integrity
学习啦在线学习网 Potential： a situation which may cause difficulty in the future.
Examples：
学习啦在线学习网 - high risk for injury
- high risk for sleep pattern disturbance
学习啦在线学习网 - high risk for impaired skin integrity
Nursing Diagnosis Statement Contains two parts：
1. The statement of the patient problem
学习啦在线学习网 2. The contributing factors or probable causes of the problem - the etiology.
学习啦在线学习网 The two parts are joined by the words "related to"
Examples：
学习啦在线学习网 1. Ineffective breathing pattern (problem) related to chest pain (etiology)。
学习啦在线学习网 2. High risk for injury (problem) related to poor vision and decreased mobility (etiology)。
学习啦在线学习网 3. Alteration in nutrition (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.
学习啦在线学习网 3. The nursing diagnosis is not a medical diagnosis - avoid using a medical diagnosis as part of the etiology.
4. Nursing diagnoses identify health problems and enable a plan of care to be developed to achieve a maximal level of wellness.
5. Use the NANDA list to help you formulate your nursing diagnosis.
学习啦在线学习网 Planning The phase of the nursing process in which you develop a plan of care and determine how you are going to solve， lessen or minimize the effects of the patient's problems.
学习啦在线学习网 There are 4 steps in this phase.
学习啦在线学习网 Step 1： Setting Priorities
学习啦在线学习网 1. Determine which problem poses the greatest threat to the patient's well-being.
- This becomes
- Continue to prioritize in this way.
学习啦在线学习网 2. Find out which problems the patient feels are most important.
Step 2： Writing Goals
1. A goal is a specific and measurable objective designed to reflect the patient's highest level of wellness and independence in function.
学习啦在线学习网 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 met fairly quickly (hours or days)
b. Long term - cover a longer time span
学习啦在线学习网 Guidelines for Goal Writing
学习啦在线学习网 1. Write goals in observable or measurable terms.
学习啦在线学习网 2. Write goals in terms of patient outcomes not nursing actions.
3. Keep goals short and specific.
4. Designate a time for achievement of the goal.
Examples of Goals
学习啦在线学习网 The patient will be free of infection throughout hospitalization.
学习啦在线学习网 The patient's lungs will remain clear postoperatively.
学习啦在线学习网 The patient's skin will be healed by 1/31.
Step 3： Developing the Expected Outcomes
Expected Outcomes define when a patient goal has been met and assist in evaluating the extent to which the nursing diagnosis has been resolved.
They are stated in observable or measurable terms.
Functions：
学习啦在线学习网 1. Provide a direction for nursing activities.
学习啦在线学习网 2. Indicate what should occur during the time span indicated in the goal.
3. Used to evaluate the effectiveness of the nursing interventions.
Example
学习啦在线学习网 Goal： The patient's lungs will remain clear postoperatively.
Expected Outcomes：
- the sputum will remain white.
- the patient will remain afebrile.
学习啦在线学习网 - the lungs will be clear to auscultation.
Step 4： Planning Nursing Actions
Nursing Actions are those things the nurse plans to do to help the patient achieve a goal.
学习啦在线学习网 Nursing Actions are derived from the etiology of the nursing diagnosis.
学习啦在线学习网 Guidelines for selecting nursing actions
1. Be sure the actions focus on the etiology of the nursing diagnosis.
学习啦在线学习网 2. Must be safe for the patient.
3. Must be congruent with other therapies.
学习啦在线学习网 4. Should be based on principles of nursing and disciplines related to nursing.
5. Must be based on appropriate rationale.
6. Each nursing diagnosis should have its own set of nursing actions.
学习啦在线学习网 7. Choose actions most likely to develop the behavior in the goal.
8. Must be realistic.
学习啦在线学习网 9. Use the patient as a source for choosing nursing actions.
学习啦在线学习网 Types of Nursing Actions
1. Dependent
学习啦在线学习网 - a nursing action based on the instruction of another professional
学习啦在线学习网 2. Independent
- requires no supervision or direction from others
3. Interdependent
- actions carried out by the nurse in collaboration with another health care professional
Questions Nursing Actions Should Answer：
1. What is the action?
2. When should the action be implemented?
3. How should the action be performed?
学习啦在线学习网 4. Who should be involved in carrying out the action?
Implementation Phase 1. Validating and documenting care.
2. Giving nursing care.
3. Continuing data collection.
Evaluation Phase 1. Evaluate goal achievement：
a. evaluate only the patient's ability to perform the behavior in the goal - don't evaluate the nursing actions.
学习啦在线学习网 2. Three alternatives：
学习啦在线学习网 a. goal met
b. goal partially met
c. goal not met
3. Include a statement of where the patient is now in terms of the expected outcomes.
4. When the goal is partially met or not met， then the care plan must be reassessed.
5. Possible outcomes：
- priorities may change and problems may have to be dealt with.
学习啦在线学习网 - new data may indicate there is a new problem to be dealt with.
- the goal may be met and the problem no longer exists.
学习啦在线学习网 - the goal may be met， but the problem still exists. May require changing goal， expected outcomes and nursing actions.
学习啦在线学习网 - 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.
学习啦在线学习网 Characteristics of Critical Thinking
1. Conceptualization
2. Rational and Reasonable
学习啦在线学习网 3. Reflective
学习啦在线学习网 4. An attitude of inquiry
5. Autonomous Thinking
6. Creative Thinking
学习啦在线学习网 7. Fair Thinking
学习啦在线学习网 8. Deciding what to believe or do