Patient-centered care procedures

Nursing procedure is a theoretical and practical model that guides the nursing staff to meet the physical and mental needs of the nursing object, restore or improve the health of the nursing object as the goal, scientifically confirm the health problems of the nursing object, and implement the planned, continuous and comprehensive holistic nursing with a systematic method.

It was first proposed by Lydia Hall in 1955;

In 1961, Johnson and other experts put forward that "nursing process is composed of a series of steps", namely assessment, planning, evaluation;

In 1966, the nursing process developed into: assessment, planning, implementation, evaluation;

In 1975, the North American Nursing Diagnostic Association proposed: Evaluation, diagnosis, Planning, implementation, evaluation.

In the nursing program, it mainly includes the four basic concepts of human, environment, health and nursing, and the nursing program is based on these four basic concepts. Human is a whole person composed of physical, psychological, social and other aspects, people have basic needs and the needs of each stage of development and growth, and interact with the environment to adapt, people are the service object of nursing in society and environment. The environment is divided into internal environment (including physiological environment and psychological environment) and external environment (including social environment and natural environment); People can adapt to the environment, change the environment, and at the same time be affected by the environment, and nursing can create an environment suitable for people to restore or maintain health. Health is a kind of positive reaction to the environment, which means that a person achieves physical, psychological and social perfection. Health and disease are interrelated a continuum, people often change in this continuum, nursing is to keep people's physical and mental, social and other aspects in the best tuned state, and can promote people's health.

Nursing runs through the whole process of human life, and the focus of nursing work is to help patients make a positive response to the disease. The nurse applies nursing procedures and communication skills to help the patient maintain a balance with the environment and achieve optimal health. Nurses promote self-care by taking care of patients; Nurses also prevent disease and maintain health.

The nursing process can generally be divided into five steps: assessment, diagnosis, planning, implementation, and evaluation. The abstract diagram is as follows:

Nursing evaluation

Evaluation is the process of collecting patient data in a planned, purposeful and systematic way. Based on the collected data and information, the nursing object and related things are roughly inferred, so as to provide the basic basis for nursing activities. Evaluation is the basis of the whole nursing procedure, and it is also the most critical step in the nursing procedure.

The purpose of evaluation: to provide basis for analyzing, judging and correctly making nursing diagnosis or nursing problems; Establishing basic data on the patient's health status; To accumulate data for nursing research.

Content of assessment: including physical, psychological, sociocultural, developmental and spiritual aspects of the data, from the perspective of holistic nursing, a comprehensive consideration of these five aspects of the life process of the data collected from 14 aspects: General status, mental and emotional status, reproductive system, environmental status, sensory status, motor status, excretion status, water/electrolyte balance status, circulation status, respiratory status, body temperature status, skin status, comfort/rest status.

Through systematic observation (looking, touching, tapping, listening, sniffing), conversation (formal or informal), nursing physical examination (physical examination, collection of nursing related physiological data) and review of records (patient's medical records, nursing records, related literature, etc.), analysis and collation of data, inferences are drawn as follows:

1) Projects with no obvious health problems should provide patients with ways to maintain and promote health;

2) Identify problem items, both existing and potential;

3) Cooperative problems must be solved through the cooperation of medical, nursing and related personnel.

Nursing diagnosis

Nursing diagnosis is a description of the physical, psychological, sociocultural, developmental and spiritual health problems in the course of a person's life. These health problems are within the scope of nursing responsibilities and can be solved by nursing methods. Nursing diagnosis is a clinical diagnosis of individual, family and community responses to existing or potential health problems or life processes, and is the basis for nurses to choose nursing measures to achieve desired outcomes.

1. Types of nursing diagnosis:

1) Existing: refers to the response to the health problem that the care object is experiencing at this moment in time;

2) Potential: refers to the presence of risk factors, if not dealt with the reaction of health problems will occur;