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.
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
学习啦在线学习网 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
学习啦在线学习网 Subjective Data
学习啦在线学习网 Information given verbally by the patient.
Examples：
学习啦在线学习网 "I itch all over."
学习啦在线学习网 "My stomach aches."
学习啦在线学习网 "I'm afraid of going to surgery tomorrow."
Methods of Collecting Data
学习啦在线学习网 1. Observation
2. Interview
a. Formal
b. Informa
c. Examination
Analysis and Interpretation of Data
1. Continually update and revise
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.
学习啦在线学习网 - alteration in comfort
- ineffective breathing pattern
- impaired skin integrity
Potential： a situation which may cause difficulty in the future.
Examples：
学习啦在线学习网 - high risk for injury
学习啦在线学习网 - high risk for sleep pattern disturbance
- high risk for impaired skin integrity
学习啦在线学习网 Nursing Diagnosis Statement Contains two parts：
学习啦在线学习网 1. The statement of the patient problem
2. The contributing factors or probable causes of the problem - the etiology.
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)。
2. High risk for injury (problem) related to poor vision and decreased mobility (etiology)。
3. Alteration in nutrition (problem) related to nausea (etiology)。
学习啦在线学习网 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.
学习啦在线学习网 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.
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.
There are 4 steps in this phase.
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.
学习啦在线学习网 - This becomes
- Continue to prioritize in this way.
2. Find out which problems the patient feels are most important.
学习啦在线学习网 Step 2： Writing Goals
学习啦在线学习网 1. A goal is a specific and measurable objective designed to reflect the patient's 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 met fairly quickly (hours or days)
学习啦在线学习网 b. Long term - cover a longer time span
Guidelines for Goal Writing
1. Write goals in observable or measurable terms.
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.
学习啦在线学习网 Examples of Goals
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.
The patient's skin will be healed by 1/31.
Step 3： Developing the Expected Outcomes
学习啦在线学习网 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：
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.
Example
Goal： The patient's lungs will remain clear postoperatively.
学习啦在线学习网 Expected Outcomes：
- the sputum will remain white.
学习啦在线学习网 - the patient will remain afebrile.
- the lungs will be clear to auscultation.
Step 4： Planning Nursing Actions
学习啦在线学习网 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.
Guidelines for selecting nursing actions
学习啦在线学习网 1. 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 disciplines related to nursing.
学习啦在线学习网 5. Must be based on appropriate rationale.
学习啦在线学习网 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.
学习啦在线学习网 8. Must be realistic.
9. Use the patient as a source for choosing nursing actions.
学习啦在线学习网 Types of Nursing Actions
学习啦在线学习网 1. Dependent
- a nursing action based on the instruction of another professional
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?
学习啦在线学习网 3. How should the action be performed?
4. Who should be involved in carrying out the action?
学习啦在线学习网 Implementation Phase 1. Validating and documenting care.
2. Giving nursing care.
学习啦在线学习网 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：
a. goal met
b. goal partially met
c. goal not met
学习啦在线学习网 3. Include a statement of where the patient is now in terms of the expected outcomes.
学习啦在线学习网 4. When the goal is partially met or not met， then the care plan must be reassessed.
5. Possible outcomes：
学习啦在线学习网 - 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 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.
- 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 Thinking
1. Conceptualization
学习啦在线学习网 2. Rational and Reasonable
3. Reflective
4. An attitude of inquiry
学习啦在线学习网 5. Autonomous Thinking
学习啦在线学习网 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