| Unit 2 Apply the Nursing Process to Nursing Chapter 1 The Nursing Process (护理程序) Definition: the nursing process is the systematic gathering of information about a patient and the effective use of this information to plan nursing care. The five major problem-solving steps in the nursing process used in this text are: Assessment（评估) ◆ purposes（目的) ◆ Kinds of assessment （评估种类) ● Subjective assessment (主观评估—病人的感觉) Subjective assessment relates to the patient’s opinion or feelings about what is happening, and for this you need to be a good listener. ● Objective assessment (客观评估) ◆ Data analysis Nursing Diagnosis（护理诊断－－病人目前的健康问题 ) Planning（计划) Plans include measures you will do with, to, and for the patient, helping him deal with the problems in the执业药师 hospital and/or home settings. These written plans provide a baseline that the total health team can use for direction and communication. (计划是指你将要为解决病人的健康问题而采取的护理措施 The nursing care plan The nursing care plan should include： ● Patient assessment（评估) ● Nursing diagnosis（护理诊断)/Patient problems ● Expected outcomes（预期目标) ● Nursing orders（护嘱) ◆ Patient problem The patient must always be viewed as an individual, and this can be accomplished only if the nurse identifies the patient’s problems from the patient point of view, rather than from nurses. In other words, the nurse’s personal views must be put aside.(应从病人的角度来确定病人的健康问题。) ◆ Expected outcomes or goals（预期目标) ● Definition: Expected outcomes are patient behaviors or clinical manifestations that represent resolution, progress toward resolution, or prevention of a problem. They may also be referred to as objectives or goals.(预期目标是指病人接受护理措施后所发生的行为或临床改变)。 ● Requirements of making expected outcomes or goals (制定预期目标的要求) &www.med126.com/wszg/nbsp; Specific; Reasonable; Understandable; Measurable; Behavioral; Achievable ◆ Nursing orders ● Definition: Nursing orders are nursing interventions or activities that will most likely produce the desired outcome or objective, be it short-term or long-term. Sometimes, specific target dates are set by the patient and the nurse. （护嘱是指护理措施或护理行动。) ● Contents of nursing order: Patient teaching Referrals Nursing actions that are likely to help achieve the desired outcome. Intervention Definition: Nursing care plans must be carried out, this is called implementation or nursing intervention（执行护理计划的过程称护理干预或护理措施). Evaluation ◆ Evaluation criteria（评价标准) Chapter 2 Nursing Process Applied to the Nursing Procedures ◆ Assessing ● The current states of the patient.(病人目前状况) ● General conditions: age, sex, weight, level of education.（一般情况) ● Systemic conditions: the state of consciousness, vital signs, ability to self-care, communicating and understanding ideas, intellectual capacity.(全身情况) ● Local conditions: hearing, vision, touch, smell, taste, motor ability, posture, skin and mucosa.（局部情况) ● Psychological status: emotional reactions, mood, the presence or absence of nerves, depression,grief and anxiety, the degree of the patient’s cooperation（心理状况) ● Health knowledge: common knowledge, related disease knowledge.（健康知识) ● Environment: the presence or absence of adequate lighting, temperature, good ventilation, and the good order of the units.（环境) ● Equipment: being in good order, all equipment being in the presence of or absence of demand.（用物) ◆ Planning ● Objection Accomplishing procedure during the given time；keeping the patient comfortable and safe； Increasing the patient’s knowledge. ● Preparation Nurses: uniform, cap, shoes, mask, washing hands; Patients: knowing the aims of the procedure, desirability of cooperating with nurses; Equipment: all equipment needed being in good order; Environment: adequate lighting, temperature, privacy. ◆ Implementing ● Communicating with the patient. ● Encouraging the patient to participate in nursing actions. ● Observing the patient reactions during the procedure. ● Documenting the outcome. ◆ Evaluating ● The presence or absence of relief and meeting his goals. ● Whether the patient is satisfied , comfortable and safe or not. | 
