Patient-centered care procedures

1) The first problem: it refers to the problem that will threaten the patient's life and need immediate action to solve, such as ineffective clearing of respiratory tract, potential violence, etc.;

2) The optimal problem: although not threatening the patient's life, but can lead to physical ill health or emotional changes, such as activity intolerance, skin integrity damage;

3) Sub-optimal problem: It refers to people dealing with development and life problems, such as malnutrition, recreational impairment, etc.

2. Set expected goals: Expected goals refer to the achievable, measurable and observable behavioral goals of patients and their families through nursing interventions. The expected goal is not nursing behavior, but can guide nursing behavior and serve as a standard for evaluating effects at the end of the work. The goal is to expect functional, cognitive, behavioral, and emotional (or feeling) changes in the nursing object after receiving nursing care.

Types of expected goals: 1) short-term goals, goals that the patient can achieve within a week, such as: the patient's stool elimination within 24 hours; The patient coughed up sputum successfully after 2 days. 2) Long-term goals, goals that take more than a week or even months to achieve, such as: patients can not develop infections during chemotherapy; The patient lost 12kg in six months.

Statement of expected goal: subject + predicate + behavior standard + adverbial of condition, such as "get out of bed with the help of a nurse and walk 50 meters each time, 3 times a day"; "After 4 days, the patient can walk 100 meters with the help of double crutches"; "Before discharge, mothers will bathe their newborns"; "During hospitalization, the patient's skin remained intact and free of bedsores".

When setting goals, we should pay attention to: 1) Goals are the results achieved by patients through nursing means, not the nursing action itself; 2) Each goal should be targeted, that is, one nursing diagnosis can specify multiple goals, but one goal can not target multiple nursing diagnoses; 3) The goal is feasible and within the patient's ability; 4) The goal should be within the scope of nursing skills, and pay attention to medical cooperation, that is, consistent with the doctor's advice; 5) The standard of conduct for objective statements should be specific to facilitate evaluation.

3. Formulation of nursing measures: Nursing measures are the work items and specific implementation methods provided by nurses for patients, and are specific activities formulated to help patients achieve their goals. These measures can be called nursing orders. The components are: date and time, action verb, specific content and method, and signature of the author.

Types of care measures: 1) dependent: measures derived from medical orders; 2) Interdependent: cooperating with other medical personnel; 3) Independent: The nurse independently proposed and taken. Among them, independent nursing measures include: helping patients to complete the activities of daily living; Therapeutic care measures; Prevention of dangerous problems; Observation of conditions and psychosocial reactions; Health education and counselling; Psychological support; Make a discharge plan.

The focus of nursing measures adopted in different nursing diagnosis problems:

1) Existing: developing measures to reduce or remove relevant factors; To monitor the functional status of patients and provide basis for treatment and nursing;

2) Potential: develop preventive measures to prevent the occurrence of dangerous conditions; Monitoring the occurrence of disease;

3) Possible: need to continue to collect data, exclusion or determination;

4) Cooperative: monitor and identify the occurrence of diseases and assist doctors in handling them.

When formulating nursing measures, it is necessary to be targeted, feasible, safe, cooperative and scientific. In the case of "patients with excessive body fluids requiring a low-salt diet," the correct description of care measures is as follows:

1) Explain to patients and their families the importance of limiting dietary sodium;

2) Tell patients and family members that daily salt intake should be <5g, that is, equivalent to half of the cola bottle cap. In addition to salty food, foods containing more sodium also include noodles, canned food, cooked food, monosodium glutamate and so on;

3) When patients eat, they should pay attention to observe and supervise whether their diet meets the requirements of low salt.

Carry out

Implementation is putting the care plan into practice. In practice, especially in cases of critical or serious illness, the implementation of the plan is usually started before the plan is formulated, and then the written part of the plan is made up.

Implementation methods include: providing care directly; Coordinate and plan the content of holistic care; Guidance and advice.

Pre-implementation preparation 4W1h: what to do; who to do (who); how to do STH. when do you do it? where do you do it?

Work contents in the implementation phase: