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护理程序英语写作范例.docx

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护理程序英语写作范例Asystematicmethodofprovidingnursingcare.Itprovidesaframeworkforplanningandimplementingnursingcare.Components1.Assessment(endswiththeformulationofanursingdiagnosis)2.Planning3.Implementation4.EvaluationAssessmentDefinition：Theprocessofgathering，verifyingandcommunicatingdataaboutapatient.Dataisgatheredfromavarietyofsourcesandisthebasisforactionsanddecisions.DataCollection1.Beginsuponadmission2.Isacontinualactionthroughouteachphaseofthenursingprocess3.DataisclassifiedaseitherobjectiveorsubjectiveObjectiveDataFactualdataobservedbythenurse.Noconclusionsorinterpretationsaremade.Examples：B/P100/62Voided200ccdarkambercoloredurineSubjectiveDataInformationgivenverballybythepatient.Examples："Iitchallover.""Mystomachaches.""I'mafraidofgoingtosurgerytomorrow."MethodsofCollectingData1.Observation2.Interviewa.Formalb.Informac.ExaminationAnalysisandInterpretationofData1.Continuallyupdateandrevise2.Clusterdata3.IdentifynursingdiagnosesNursingDiagnosisAstatementofanactualorpotentialresponsetoahealthproblemthatthenurseiscompetentandlicensedtotreat.Actual：asituationthatexistsinthehereandnow.-alterationincomfort-ineffectivebreathingpattern-impairedskinintegrityPotential：asituationwhichmaycausedifficultyinthefuture.Examples：-highriskforinjury-highriskforsleeppatterndisturbance-highriskforimpairedskinintegrityNursingDiagnosisStatementContainstwoparts：1.Thestatementofthepatientproblem2.Thecontributingfactorsorprobablecausesoftheproblem-theetiology.Thetwopartsarejoinedbythewords"relatedto"Examples：1.Ineffectivebreathingpattern(problem)relatedtochestpain(etiology)。2.Highriskforinjury(problem)relatedtopoorvisionanddecreasedmobility(etiology)。3.Alterationinnutrition(problem)relatedtonausea(etiology)。Thingstoremember：1.Onlyonenursingdiagnosisperpatientproblem.2.Eachnursingdiagnosiscanhavemorethanoneetiology.3.Thenursingdiagnosisisnotamedicaldiagnosis-avoidusingamedicaldiagnosisaspartoftheetiology.4.Nursingdiagnosesidentifyhealthproblemsandenableaplanofcaretobedevelopedtoachieveamaxima