《护理学导论》英文讲义 第十章护理程序.docx
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《护理学导论》英文讲义 第十章护理程序.docx
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《护理学导论》英文讲义第十章护理程序
Introductiontonursing
Chapter10Nursingprocess
Section1Nursingprocessandassessing
Contentsoutline
Historicalperspective
Descriptionofnursingprocess
Characteristicsofnursingprocess
Assessment
Definition
Purpose
Typesandcharacteristicsofdata
Sourcesofdata
Methodsofdatacollection
Objectives
Afterstudyingthissession,thestudentsshouldbeableto:
1.Stateconceptofnursingprocess
2.Statefivesteps(phases)ofnursingprocess
3.Definethemajorcharacteristicsofnursingprocess
4.Stateconceptofassessing
5.Differentiateobjectivedataandsubjectivedata
6.Identifysourcesofdata
7.Applythemethodscorrectlyindatacollection
KeyPoints
1.Conceptofnursingprocess
2.Steps(phases)ofnursingprocess
3.Characteristicsofnursingprocess
4.Conceptofassessing
DifficultPoints
1.Typesofdata
2.Sourcesofdata
3.Applythemethodscorrectlyindatacollection
Contents
1.Historicalperspective
In1955,LydiaHallintroducednursingprocess
1960-1973,nursingtheoristshadbeenverifyingstepsofnursingprocess
1973,ANApublishedthe“StandardsofNursingPractice”,thefivenursingprocessmodelisdescribedinstandardsofnursingpractice.
1980,furthercommitmentbytheANAtothefive-stepnursingprocessmodelwasdocumentedinthe1980“NursingandSocialPolicyStatement”,thismadethismodelthestandardforprofessionalnursingpracticein1991,RevisionoftheANA“StandardsofclinicalNursingPractice”continuestousethefive-stepmodel.
2.Descriptionofnursingprocess
Asystematicmethodthatdirectsthenursingandclienttogether
1)Determinetheneedfornursingcare
2)Planandimplementthecare
3)Evaluatetheresults
4)Five-stepnursingprocessmodel
2.1Assessing
establishesthedatabase
continuouslyupdatesthedatabase
validatesdata
communicatesdata
2.2Diagnosing
interpretsandanalyzesclientdata
identifiesclientstrengths,healthproblem
formulates,validatesnursingdiagnoses
developsaprioritizedlistnursingdiagnose
2.3Planning
establishespriorities
writesexpectedoutcomes
develops,selectsnursinginterventions
communicatestheplanofcare
2.4Implementing
carriesouttheplanofcare
continuescollectingdataandmodifiestheplan
documentscare
2.5Evaluating
measuresdesiredoutcomes
identifiesfactorscontributingtofailure
modifiestheplanofcare
Thefivestepsinnursingprocessareinterrelated,eachofthefivestepsdependsontheaccuracyofthestepsprecedingit.Theprocessprovidesaframeworkthatenablethenursetoprovideeffectivecaretotheclients.
3.Characteristicsofnursingprocess
3.1Systematic
Eachstepdependsontheaccuracyofthepreviousstepandinfluencesthenextstep.Thenursingprocessdirectseachstepofnursingcareinasequentialmanner.
3.2Interpersonal
Ensurethatnursesareclient-centeredratherthantasked-centered
3.3Goal-oriented
Offerameansfornursesandclientstoworktogethertoidentifyspecifichealthgoalswhicharemostimportanttotheclient:
improvingtheiroralhygiene,livewithpain,recoverfromanacutemedicalillness,preventionrecurrence,orpreparefordeath
4.Assessing
4.1Definition
Aprocessofgathering,verifying,andcommunicatingdataaboutaclient
4.2Purpose
4.2.2toobtainrelevantinformationaboutthestrengthsandneedsofclients
4.2.3toestablishadatabaseaboutclients:
pt,familypatternsofhealthandillness,deviationfromnormal,strengths,copingabilitiesandriskfactorsforhealthproblem
4.2.4toestablishadatabaseforplanningcare
4.3Typesofdata
4.3.1Subjectivedata
Client’sperceptionsabouttheirhealthproblems
4.3.2Objectivedata
Observationsormeasurementsmadebythedatacollectorbasedonanacceptedstandard
4.4Characteristicsofdata
4.4.1Complete
Alltheclientdataneeded
4.4.2Factualandaccurate
Recordingtheclient’sbehaviors,factually
4.4.3Relevant
Whatandhow:
whattypeofdataandhowmuchdatatocollectforeachclient.
4.5Sourcesofdata
4.5.1Primary
Client
.Healthcareneeds
·Lifestyle
·Presentandpastillness
·Perceptionofsymptoms
·Changesinactivities
4.5.2Secondary
.Nurse’sownObservations
.Family,members,friends,Supportpeople
4.5.3Tertiary
Clientrecord
·
.healthrecord:
age,sex,occupation,religiouspreference,financialstatus
·medicalhistory
·physicalexamination
·progressnotes
·consultations
.diagnosticstudy:
bloodanalysis,urineanalysis,radiologicalexamination,stoolanalysis,sputumanalysis,andothers:
electrocardiogramECG,stresstest,tuberculosisTBskintest
Otherhealthcareprofessionals
.Literature:
consultthenursingandrelatedliteratureonspecifichealthproblems.
4.5Methodsofdatacollection
4.5.1Observation
useofthefivephysicalsenses(hearing,seeing,tactile触觉,smell嗅觉,taste,味觉)togatherdata
client’scurrentresponsetosituation.
client’scurrentabilitytomanagehiscare,needforadditionalinformationornursingassistance?
theimmediateenvironment
thelargerenvironment
4.5.2Interview
Apatternofplannedcommunicationforaspecificpurposeandfocusedonaspecificcontentarea
4.5.3Nursinghealthhistory
reasonforseekinghealthcare:
goalsofcare,expectationoftheservicesandcaredelivered,andexpectationofthehealthcaresystem
presentillnessorhealthconcern:
onset,symptoms,natureofsymptoms,duration,precipitatingfactors,reliefmeasures,andweightlossorgain
pasthealthhistory,habits,prescribedandself-prescribedmedications,workhabits,relaxationactivities,andsleep,exercise,andeatingornutritionalpatterns.
familyhistory:
healthstatusoftheimmediatefamilyandlivingrelatives.
environmentalhistory:
hazards,pollutants,andphysicalsafety.
psychosocialandculturalhistory:
reviewofsystem:
head-totoereviewofallmajorbodysystems,aswellastheclient’sknowledgeofandcompliancewithhealthcare.
expectationsofcare
abilityandwillingnesstoparticipateinthecare
personalresourcesanddeficits
Initiatingofaninterview
Thenurseinitiatestheinterviewbystatinghisorhernameandstatus,identifyingthepurposeoftheinterview,andclarifyingtherolesofnurseandclient.
4.5.3Physicalassessment
Takingofvitalsignsandothermeasurementsandtheexaminationofallbodypartsusingthetechniquesofinspection,palpation,percussion,andauscultation.
Generalsurvey
measuringheight,weight,andvitalsigns
head-to-toeexaminationofthebodysystems
4.6Sorting,validatingdata
Organizestheinformationintomeaningfulclustersbyusing
System-orientedformat
Functionalhealthpatternformat
focusesattentiononfunctionsneedingsupportandassistanceforrecovery
confirmingorverifyingsoastokeepdataasfreefromerror,bias,andmisinterpretationaspossible
4.7Datadocumentation
•Essentialfortworeasons
•alldatapertinenttoclientstatusareincluded
•legalandprofessionalresponsibility
•Datashouldbesummarizedandenteredintocomputerorrecordedinink
•usingthedesignatedagencyforms
•Datashouldbewrittenlegibly,goodgrammarUsestandardmedicalabbreviations
Criticalthinkingexercise
Workingwithanotherstudent,togetherinterviewclientsinbothhomeandinstitutionalsettings.Makealistoftheobjectiveandsubjectivedatayougatheroneachclientinterviewedandcompareyourdatalists.Explorethereasonsforthedifferencesyoudiscoveramongclients,betweenhomeandresidentialsettings,andbetweenwhatyouandyourpartnerdecidetorecord.
Section2NursingDiagnosis
Objectives:
1.Afterstudyingthissession,thestudentsshouldbeableto
2.Definetheconceptofnursingdiagnosis.
3.Definetheconceptofcollaborativeproblems
4.DescribeimportanceandpurposesofND
5.DescribeandidentifycategoriesofND
6.Stateformatforwritingdiagnosticstatements
Keypoints
1.Conceptofnursingdiagnosis
2.Conceptofcollaborativeproblems
3.PurposesofND
4.Difficultpoints
Contents
1.Revision
Thediscussionofnursingasascienceandaprofessiondescribednursingashavingindependent,interdependent,anddependentfunctions.Asnursesinterpretandanalyzeclientdata,nurseidentifieswhatitisabouttheclientthatisnurse’suniqueconcern,nursingdiagnosesarethereforewrittentodescribeclientproblemsthatnursescantreatindependently;theymayidentifyhealthproblemsthatarebettertreatedbyphysicians(medicaldiagnoses)orbynursesworkingwithotherhealthcareprofessionals(collaborativeproblems).
Thediscussionofnursingdiagnosishasfocusedprimarilyonthoseproblemsthatarewithinthedomainofnurse’sindependentfunction.Theseareproblemsforwhichnursescanlegallydeterminetheactionstoprevent,solve,orrelievetheproblems.
Manyofclientshavediagnosedmedicalproblems(disease).Thesesameclientshavealikehoodofdevelopingdifficultiesorpotentialcomplicationsrelatedtoadiseaseortomedicalorsurgicalinterventionsusedtotreatthedisease.Otherclientsareatriskfordevelopingmedicalcomplicationsfromdiagnostictests,whetherornottheyhaveactualdisease.Theseactualorpotentialproblemsareoutsidethenurse’sindependentfunction,,aredesignatedas“collaborativeproblems”.
Diagnosing:
isphase2ofthenursingprocess.Thisphaseincludesanalyzingdata,formulatingnursingdiagnoses,andidentifyingstrengthsandproblems/needsofclients.
Analyzingdata:
focalpointsareboththeclients’strengthsandneeds
Nursingdiagnoses:
summarizetheclients’
Analyzing:
isanimportantmentalactivityt
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