护理程序写作指南
Writing The Nursing Process
Definition
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."
"I'm 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 patient's problems.
There are 4 steps in this phase.
Step 1: Setting Priorities
1. Determine which problem poses the greatest threat to the patient's well-being.
- This becomes #1
- 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 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)
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 patient's lungs will remain clear postoperatively.
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:
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.
Expected Outcomes:
- the sputum will remain white.
- the patient will remain afebrile.
- 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.
Nursing Actions are derived from the etiology of the nursing diagnosis.
Guidelines for selecting nursing actions
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.
5. Must be based on appropriate rationale.
6. Each nursing diagnosis should have its own set of nursing actions.
7. Choose actions most likely to develop the behavior in the goal.
8. Must be realistic.
9. Use the patient as a source for choosing nursing actions.
Types of Nursing Actions
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?
3. How should the action be performed?
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.
2. Three alternatives:
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.
- new data may indicate there is a new problem to be dealt with.
- the goal may be met and the problem no longer exists.
- 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
2. Rational and Reasonable
3. Reflective
4. An attitude of inquiry
5. Autonomous Thinking
6. Creative Thinking
7. Fair Thinking
8. Deciding what to believe or do
Treatment of Pressure Ulcers
Various topical agents have been used in treating pressure ulcers. Some of these agents (e.g., astringents, alkaline soap products) have proven harmful. Beneficial agents include enzymes, antiseptics, oxidizing agents, and dry dextranomer beads.
The agent of choice depends on the depth of the ulcer. Deeper ulcers may derive greater benefit from enzyme application.
Local treatment of pressure ulcers also includes using various dressings. The occlusive dressings are a group of dressings that are widely marketed and are being used with increasing frequency to treat pressure ulcers. These dressings (including transparent dressings, hydrocolloid dressings, and hydrogels) may be used in combination with topical agents or by themselves.
Equipment
Wash basin, soap, water, cleansing agent or prescribed topical agents, ordered dressings, skin protectant, cotton-tipped applicators, hypoallergenic tape or adhesive dressing sheet (Hypofix), disposable and sterile gloves, measuring device
Steps and Rationale
1. Wash hands and don gloves.
* Reduces transmission of blood-borne pathogens. Gloves should be worn when handling items soiled by body fluids.
2. Close room door or bedside curtains.
* Maintains client's privacy.
3. Position client comfortably with area of decubitus ulcer and surrounding skin easily accessible.
* Area should be accessible for cleansing of ulcer and surrounding skin.
4. Assess pressure ulcer and surrounding skin to determine ulcer stage (Table 3).
a. Note color, moisture, and appearance of skin around ulcer.
* Skin condition may indicate progressive tissue damage. Retained moisture causes maceration.
b. Measure two perpendicular diameters.
* Provides an objective measure of wound size. May determine type of dressing chosen. Surface area = length (L) x width (W).
c. Measure depth of pressure ulcer using a sterile cotton-tipped applicator or other device that will allow a measurement of wound depth.
* Depth measure is important for determining wound volume. Although surface area adequately represents tissue loss in stage 1 and 2 ulcers, volume more adequately represents tissue loss in the deeper stage 3 through 4 wounds.
Volume = 2(L x D) + 2 (W x D) + (L + D)
d. Measure depth (D) of skin undermined by lateral tissue necrosis. Use a sterile cotton-tipped applicator and gently probe under skin edges.
* Undermining represents the loss of underlying tissues to a greater extent than that of the skin. Undermining may indicate progressive tissue necrosis.
5. Wash skin surrounding ulcer gently with warm water and soap. Rinse area thoroughly with water.
* Cleansing of skin surface reduces number of resident bacteria. Soap can be irritating to skin.
6. Gently dry skin thoroughly by patting lightly with towel.
* Retained moisture causes maceration of skin layers.
7. Apply sterile gloves.
* Aseptic technique must be maintained during cleansing, measuring, and application of dressings. (Check institutional policy regarding use of clean or sterile gloves.)
8. Cleanse ulcer thoroughly with normal saline or cleansing agent.
* Removes debris of digested material from wound. Previously applied enzymes may require soaking for removal.
a. Use irrigating syringe for deep ulcers.
b. Cleansing may be accomplished in the shower with a hand-held shower head.
c. Whirlpool treatments may be used to assist with wound cleansing and debridement.
9. Apply topical agents, if prescribed (Table 4):
Enzymes
l Keeping gloves sterile, place small amount of enzyme ointment in palm of hand.
* It is not necessary to apply thick layer of ointment. A thin layer absorbs and acts more effectively. Excess medication can irritate surrounding skin. Apply only to necrotic areas.
l Soften medication by rubbing briskly in palm of hand.
* Makes ointment easier to apply to ulcer.
l Apply thin, even layer of ointment over necrotic areas of ulcer. Do not apply enzyme to surrounding skin.
* Proper distribution of ointment ensures effective action. Enzyme can cause burning, paresthesia, and dermatitis to surrounding skin.
l Moisten gauze dressing in saline and apply directly over ulcer.
* Protects wound. Keeping ulcer surface moist reduces time needed for healing. Skin cells normally live in moist environment.
l Cover moistened gauze with single piece of dry gauze and tape securely in place.
* Prevents bacteria from entering moist dressing.
Antiseptics
l Deep ulcers: apply antiseptic ointment to dominant gloved hand and spread ointment in and around ulcer. (Avoid spread of contamination if area is infected.)
* Antiseptic ointment causes minimal tissue irritation. All surfaces of wound must be covered to effectively control bacterial growth.
l Apply sterile gauze pad over ulcer and tape securely in place.
* Protects ulcer and prevents removal of ointment during turning or repositioning.
Dextranomer Beads
l Hold container of beads approximately I inch (2.5 cm) above ulcer site and lightly sprinkle 5 mm-diameter layer over wound.
* Layer of insoluble powder is needed to absorb wound exudate.
l Apply gauze dressing over ulcer.
* Holds beads in place and protects wound.
Hydrocolloid Beads/Paste
l Fill ulcer defect to approximately half of the total depth with hydrocolloid beads or paste.
* Hydrocolloid beads/paste will assist in absorbing wound drainage. Highly draining wounds are best treated with hydrocolloid beads/granules.
l Cover with hydrocolloid dressing; extend dressing 1 to 1 1/2 inches beyond edges of wound.
* Dressing maintains wound humidity. May be left in place up to 7 days.
Hydrogel Agents
l Cover surface of ulcer with hydrogel using sterile applicator or gloved hand.
* Maintains wound humidity while absorbing excess drainage. May be used as a carrier for topical agents.
l Apply dry, fluffy gauze over gel to completely cover ulcer.
* Holds hydrogel against wound surface, is absorbent.
Calcium Alginates
l Pack wound with alginate using applicator or gloved hand.
* Maintains wound humidity while absorbing excess drainage.
l Apply dry gauze, foam, or hydrocolloid over alginate.
* Holds alginate against wound surface
10. Reposition client comfortably off pressure ulcer.
* Avoids accidental removal of dressings.
11. Remove gloves and dispose of soiled supplies. Wash hands.
* Prevents transmission of microorganisms.
12. Record appearance of ulcer and treatment (type of topical agent used, dressing applied, and client's response) in nurse's notes.
* Baseline observations and subsequent inspections reveal progress of healing. Documents care.
13. Report any deterioration in ulcer's appearance to nurse in charge or physician.
* Deterioration of condition may indicate need for additional therapy.
Nurse Alert
Early ulcers tend to have irregular borders; with time, borders become smooth and rounded. If wound is large, irrigating with plain sterile water from an irrigating syringe may be helpful.
Teaching Considerations
All individuals participating in client's wound care should be taught the correct method to administer ulcer care.
Geriatric Considerations
Medicare regulations limit reimbursement for some types of pressure relief equipment used for Stages 3, 4, and 5 pressure ulcers.
Description of Appearance
Stage I: Nonblanchable erythema of the intact skin; may be soft or indurated; edge is usually irregular.
Stage II: Partial-thickness skin loss involves epidermis and/or dermis. Ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
Stage III: Full-thickness skin loss involves damage or necrosis of subcutaneous tissue that may extend to the fascia. Ulcer presents clinically as a deep crater, with or without undermining of adjacent skin.
Stage IV: Full-thickness skin loss occurs with extensive destruction or necrosis through subcutaneous layers into muscle and bone. Ulcer edge appears to "roll over" into the defect and is a tough fibrinous ring.
Stage V: Lesion is covered by a tough membranous layer that may be rigidly adherent to the ulcer base. Stage is difficult to determine until eschar has sloughed or has been surgically removed
译文:
压疮的治疗
主任医师（讲课）
Professor of Medicine
主任医师（医疗）
Professor of Treatment儿科主任医师
Professor of Paediatrics主治医师
Doctor-in-charge外科主治医师
Surgeon-in-charge内科主治医师
Physician-in-charge眼科主治医师
Oculist-in-charge妇科主治医师
Gynaecologist-in-charge牙科主治医师
Dentist-in-charge医师
Doctor医士
Assistant Doctor主任药师
Professor of Pharmacy主管药师
Pharmacist-in-charge药师
Pharmacist药士
Assistant Pharmacist主任护师
Professor of Nursing主管护师
Nurse-in-charge护师
Nurse Practitioner护士
Nurse主任技师
Senior Technologist主管技师
Technologist-in-charge技师
Technologist技士
Technician作者: 512test 时间: 2008-11-26 20:47:02
其他类医学英文名称
medical apparatus and instruments: 医疗器械
pharmaceutical factory: 药厂
drugstore; chemist's shop; pharmacy: 药店
pharmacopeia: 药典
prescription: 药方
write out a prescription: 开药方
drugstore; chemist's shop; pharmacy: 医药商店
hospital pharmacy; dispensary: 医院或诊所里的药房
expenses for medicine; charges for medicine: 药费
a pot for decocting herbal medicine: 药罐子
chronic invalid: 药罐子（经常生病的人）
apothecaries'measure or weight: 药衡
medicinal herb collector; herbalist 药农
herbal medicine shop: 药铺作者: 512test 时间: 2008-11-26 20:47:24
不同种类医院的英译
hospital: 医院
hospital for infectious diseases:传染病医院
children's hospital: 儿童医院
obstetrics and gynecology hospital:妇产医院
tuberculosis hospital: 结核病医院
stomatological hospital: 口腔医院
army hospital: 陆军医院
field hospital: 野战医院
hospital of chinese medicine: 中医医院
tumor hospita;: 肿瘤医院
general hospital: 综合性医院
mental hospital: 精神病院
hospital for lepers;leprosarium: 麻风病院
sanatorium: 疗养院
clinic: 诊疗所
first-aid station: 急救站
quarantine station: 防疫站
laboratory technician: 化验员
nurse: 护士
head nurse: 护士长
anesthetist: 麻醉师
pharmacist; druggist: 药剂师
out-patient: 门诊病人
emergency case: 急诊病人
cure; treat; heal: 医治
healing of burns: 医治烧伤
fail to respond to any medical treatment: 医治无效
doctor's advice: 医嘱
take medicine according to doctor's orders:遵照医嘱服药
assistant doctor: 医助作者: 傅立兔 时间: 2011-4-3 16:18:28
