Patient-centered care procedures

3) Possible: Suspect factors exist, but clues are insufficient, and further data collection is needed to rule out or confirm a tentative nursing diagnosis;

4) Healthy: refers to individuals, families and communities from a specific level of health to a higher level of health care diagnosis;

5) Syndrome: refers to a set of existing or risky nursing diagnoses caused by a specific situation or event.

2. Components of nursing diagnosis: name, definition, diagnostic basis, related factors; Among them, the relevant factors come from: pathophysiology, psychology, treatment-related, situational aspects, maturity aspects; Take clearing the breath to ineffectiveness as an example statement:

Name: Clearing the respiratory tract is ineffective

Definition: A condition in which an individual is unable to clear secretions and obstructions from the respiratory tract to maintain an open airway.

Diagnostic basis:

Main evidence: 1) the cough is weak or ineffective; 2) Inability to discharge respiratory secretions;

Secondary evidence: 1) Abnormal breathing sound, bubble sound or dry singing sound; 2) Changes in respiratory depth, rate and rhythm; 3) Bluish or pale complexion.

Related factors: 1) physical causes such as respiratory inflammation, fear of cough or inability to cough, neurological diseases such as polyradiculitis, tonsil or gland edema hypertrophy or congenital abnormalities; 2) Therapeutic reasons such as surgery; 3) Situational aspects such as improper temperature and humidity of the surrounding environment, fear and anxiety about the environment; 4) In terms of growth and development, newborns have imperfect respiratory system development, children have trachea foreign bodies, and the elderly have reduced activity and poor reflexia.

3. Presentation: The statement of a complete nursing diagnosis consists of three parts, namely, Problem, Etiology, Symptoms or Signs, so it is also known as the PES formula.

The three-part statement is mostly used for existing nursing diagnoses, such as: impaired gas exchange (P), cyanosis, respiratory distress (S), associated with obstructive emphysema (E); Abnormal bowel movements (P), diarrhea (S), caused by indigestion (E);

The two-part statement (PE or SE) is mostly used for potential nursing diagnoses, and the paradigm is: "there is a risk" of nursing diagnoses, such as risk of skin integrity impairment (P), associated with prolonged bed rest (E);

Part of the statement is that there are no relevant factors, often used in health care diagnosis, paradigm: effective implementation of treatment programs, such as potential mental health enhancement.

Nursing diagnosis and cooperative problems

In 1983, Lynda Carpentino put forward the concept of "cooperative problems", believing that the problems requiring nursing care provided by nurses can be divided into two categories: one can be solved by nursing orders provided by nurses, which belongs to nursing diagnosis; The other type of problem is to work with other medical personnel, especially doctors, and nurses mainly provide monitoring care, which is a cooperative problem.

Cooperative problems are those that nurses cannot prevent and deal with independently. Nurses are required to monitor the occurrence and change of physiological complications in a timely manner, and nurses are required to jointly deal with medical instructions and nursing measures to reduce complications.

Note: Not all complications are cooperative.

The difference between nursing diagnosis and medical diagnosis: medical diagnosis is a name to describe a disease, a set of symptoms and signs of the case changes; Nursing diagnosis is the description of a patient's behavioral response to a pathological condition, with the purpose of developing and implementing a nursing plan to address the patient's existing or potential health problems.

When writing nursing diagnosis, attention should be paid to: 1) the nursing problems listed are clear and simple to understand; 2) One diagnosis for one problem; 3) There must be clear subjective and objective data as the basis; 4) The reasons are clear; 5) The identified problem needs to be solved by nursing measures; 6) When writing reasons, statements that cannot give rise to legal disputes.

Nursing plan

The decision-making process of how to address a nursing problem in the development of a nursing plan, the purpose of which is to identify the objectives of the nursing focus of the patient and the nursing measures to be implemented by the nurse. Nursing planning is the process of making nursing plan according to the confirmed nursing diagnosis, that is, the specific decision-making process, which is the action guide for the implementation of nursing care for patients, covering admission nursing plan, hospitalization nursing plan and discharge nursing plan.

1. Arrange the order of nursing: that is, determine the focus of nursing, a patient can have multiple nursing problems at the same time, formulate a nursing plan should be based on its importance and urgency to discharge the primary and secondary, generally put the biggest threat in the first place, the other order, so that the nurse can according to light, heavy, slow, urgent planned work, sorting rules: