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;

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:

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:

1) Continue to collect data, constantly discover new nursing problems, reevaluate nursing objects, and develop new plans and measures.

2) Implement nursing measures as planned.

3) Oral shift and written shift report, the execution of nursing procedures within 24 hours is continuous.

4) Writing nursing records, using PIO recording methods, namely Problem, Intervention and Outcome.

evaluate

Evaluation is the activity of comparing the patient's health status with the expected nursing goal in a planned and systematic way. In the implementation of nursing procedures, the focus of evaluation is the patient's health status, and the responsibility for evaluation is borne by the responsible nurse.

The purpose of evaluation: 1) to determine whether the patient has achieved the expected effect or goal; 2) Review the nursing procedures to determine whether the nursing assessment is comprehensive, the nursing diagnosis is correct, and the nursing plan is appropriate.

Content of evaluation: physical appearance and function; Special symptoms and signs; Knowledge aspect; Operational skills; Psychological and emotional aspects. It is used to measure the degree of achievement of the goal: the goal is fully achieved, the goal is partially achieved, and the goal is not achieved.

Evaluation methods: investigation, comparison, observation, statistical analysis;

Evaluation steps: collect data, judge the effect, analyze the reasons, and revise the plan (stop, revise, delete, add).

Forms of evaluation: nursing round, nursing consultation, discharge nursing record discussion, nursing record quality evaluation.