护理程序英语写作范例 A systematic method of providing nursing care. It provides a framework for planning and implementing nursing care. 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 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： B/P 100/62 Voided 200cc dark amber colored urine Subjective Data Information given verbally by the patient. Examples： I itch all over. My stomach aches. Im afraid of going to surgery tomorrow. Methods of Collecting Data 1. Observation 2. Interview a. Formal b. Informa c. Examination Analysis and Interpretation of Data 1. Continually update and revise 2. Cluster data 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. Actual： a situation that exists in the here and now. - alteration in comfort - ineffective breathing pattern - impaired skin integrity Potential： a situation which may cause difficulty in the future. Examples： - high risk for injury - high risk for sleep pattern disturbance - high risk for impaired skin integrity Nursing Diagnosis Statement Contains two parts： 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： 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) 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 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 patients problems. There are 4 steps in this phase. Step 1： Setting Priorities 1. Determine which problem poses the greatest threat to the patients well-being. - This becomes - Continue to prioritize in this way. 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 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 met fairly quickly (hours or days) 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. Examples of Goals The 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 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： 1. Pro。