(A) Nursing evaluation
Evaluation is the beginning of nursing procedure, and it is a process in which nurses collect the data of nursing objects purposefully, systematically and step by step through talking with patients, observing and nursing physical examination, so as to provide reliable basis for nursing activities. Whether the evaluation is accurate or not directly affects the determination of nursing diagnosis, the formulation and implementation of nursing plan and the realization of nursing goals. In the process of implementing nursing procedures, patients should be evaluated at any time, so as to determine the progress of the disease in time, find new problems during hospitalization and adjust the nursing plan in time. Therefore, evaluation runs through the whole nursing process.
(2) Nursing diagnosis
1. The concept of nursing diagnosis is a clinical judgment about the response of individuals, families or communities to existing or potential health problems or life processes, and it is the basis for nurses to choose nursing measures to achieve the expected goals (expected results), which is formulated by nurses.
2. Composition of nursing diagnosis Nursing diagnosis consists of four parts: name, definition, diagnosis basis and related factors.
3. Nursing diagnosis statement The nursing diagnosis statement includes three elements: question (P) and the name of nursing diagnosis; Correlation factor (e) is often expressed as "correlation"; Symptoms and signs. Also known as PES formula.
4. Problems that should be paid attention to when writing nursing diagnosis.
5. The cooperation between doctors and nurses refers to the problem that can only be solved by the cooperation between nurses and doctors, and refers to the potential complications caused by pathological and physiological changes of organs.
6. Differences and connections between nursing diagnosis and medical diagnosis.
(3) Nursing plan
Nursing plan is a specific nursing measure for nursing diagnosis and a guide for nursing action. The purpose of planning is to make patients get personalized care, maintain the continuity of nursing work, promote communication between medical staff and facilitate evaluation. Generally, it is carried out in four steps.
(4) implementation
Implementation is the process of putting all planned measures into action to achieve nursing goals. The implementation usually occurs after the nursing plan, but for emergency patients or critically ill patients, emergency rescue measures should be taken first, and then a complete plan should be written.
(5) Evaluation
Evaluation is a process of comparing patients' health status with expected goals in a planned and systematic way and making judgments. Through the evaluation, we can know whether the patient has achieved the expected nursing goal. Although evaluation is the last step of nursing activities, evaluation actually runs through the whole process of nursing activities.