Who can help me find a nursing review of Pham Van Jiqiu!! One, care is estimated that (a) of the definition of all aspects step by step, there are plans to collect data to assess the health status of patients during that estimate. Estimate is the beginning of nursing program, estimated phase is to provide high quality care and individualized basis to determine each patient's nursing diagnosis, goal setting, implementation and evaluation of nursing care plans, providing a basis. Therefore, the importance of collecting data, in addition to general admission for the first time estimates, the implementation process in the nursing program, the patients should also be estimated with the progress, will help in a timely manner to determine the progress of patients and found that patients during the emergence of new problems, based on this information to decide whether to modify, suspend or continue nursing. (B) to collect information on the content and scope of data collection to the people's basic needs should be based, patient-centered to think that the patient's health condition and his reaction to the current disease, the nurse should be most concerned about and solve problems. Therefore, nurses should focus on understanding the patient's health status, growth and development status, lifestyle, environment and disease physiological and psychological reactions. How to help patients recover in order to facilitate optimal functional status and decision-making. In the collection of data from the following 14 aspects: 1. Social and psychological status (1) social conditions, including the patient's occupation, unit, job, economy, education, religion and people who affect the lives of patients. (2) family status of family members, the patient's role in the family and living conditions. 2. Mental emotional state (1) perception, so that patients tell their own where, today is the day of the month, to identify people and check their writing and speaking ability and vocabulary level. (2) the patient's response to stress. (3) on the surrounding people and things, and material response, whether previously hospitalized, whether the fear of the hospital and so on. (4) the patient is currently considering the question, What are the requirements for nursing care. (5) the patient's views on the current situation and their own self-image concept and want to be healthy. 3. Asexual reproductive system function changes. Women should be aware of the history of menstruation, childbirth cases, family planning and so on. 4. The environment (1) sense of security. (2) from the patient's age or mental condition analysis, the need for security measures such as bed rails and so on. (3) whether there are environmental factors that cause cross-infection. 5. Feel the situation (1) visual acuity, light reflex, with or without visual hallucination, hallucinations. (2) whether hearing voices clearly heard general, whether monaural or binaural hearing problems, with or without tinnitus. (3) patients with olfactory sense of smell is different. (4) the existence of simple taste and basic taste, with or without different. (5) includes a variety of tactile pain, hot and cold, and the feeling of touch and so on. 6. Activities nerve conditions (1) whether the action is limited and the status of activities of daily activities and violent activities in sustainability. (2) The joint activities of musculoskeletal conditions, grip size, walk way, if you want the help of crutches and other tools, with or without limbs, muscle atrophy, flaccid paralysis and so on. 7. Nutritional status (1) eating habits and likes to eat a day how much to eat what is often a sense of fullness or hunger, the availability of picky habits. (2) height, weight and activity are too thin or obese, and nearly level with or without weight loss, and by observing the skin, nails, etc. to understand nutrition. (3) whether the recent changes in appetite and condition, the factors which affect appetite. (4) the digestive system without dentures, missing teeth, dysphagia, nausea, vomiting, gastrointestinal tract, with or without surgery, whether for special examination, treatment or medication affect the digestion and appetite. 8. Discharge status (1) patients with normal excretory habits, whether there are changes now. (2) What methods help patients normal excretion. (3) reasons for the changes caused by drainage conditions. (4) excretion method is changed, the need for ancillary facilities. (5) whether other special issues recently, such as incontinence, constipation, diarrhea, urinary retention, urinary incontinence, urinary frequency, nocturnal enuresis and so on. 9. Water and electrolyte balance (1) normal uptake and excretion, such as daily appetite, fluid intake volume, and urine output and so on. (2) any special health problems affecting the normal intake, with or without drink or not drink, are the reasons, with or without edema, signs of dehydration. (3) Check the pH of blood electrolytes understand the situation, understand the circulating blood volume measurement of blood pressure. 10. Loop condition (1) pulse rate, strength, rhythm, pulse type. (2) heart sound is normal, heart rate and pulse rate are the same. (3) blood pressure is normal, were detected to be upright blood pressure, supine blood pressure and blood pressure in both upper limbs. (4) observation of the skin, lips, nails, understand the situation of peripheral circulation. (5) cardiac care data reports and images. (6) The laboratory and clinical significance. 11. Respiratory conditions (1) whether the direct observation of airway patency, respiratory rate, breath sounds, body posture on respiration. (2) indirectly observe whether the smoking history, daily smoking, the type of tobacco; around whether smokers; without taking drugs that affect the respiratory system function; whether there is anxiety, fear of affecting the respiratory situation; whether breathing machines, oxygen ventilation; skin, lips, nail color and type; laboratory findings and clinical significance. 12. Temperature conditions (1) patients complained of feelings of self temperature. (2) patients (family members) aware of fever and chills when the warm temperature of general measures. (3) measurement of body temperature, to understand the basis of body temperature. (4) sweating time, manner, or without night sweats. 13. Skin condition (1) skin color, flexibility, humidity, completeness, or without subcutaneous bleeding, pressure sores and other injuries. (2) hygiene and skin excretion. 14. Comfort and rest conditions (1) causes discomfort and what measures can make the patient feel comfortable. (2) sleep enough, to borrow the means to help sleep disorders affect sleep or some other reason, whether it was daytime sleepiness, fatigue. Nurses from the 14 aspects of patient information to understand, to see whether the patient is able to meet, if found not to meet the basic needs of a particular, then find the reason. (C) information on the type of information include the type of subjective and objective data, information on past and present, fixed and variable information. 1. Subjective and objective information that the patient's subjective complaints information, including disease, feelings, attitudes, aspirations and needs. Such as nausea, dizziness, pain and other subjective information. Observation of objective information that health care workers. Through observation, measurement, physical examination or laboratory tests to determine if the patient's height, weight, blood pressure, are all objective information. Subjective and objective health information to provide information to patients and help identify problems. 2. Past and present information on past data that occurred in previous events. Including past history, patient history, family history, and history of other healthy habits. Information that is now existing. Such as blood pressure, vomiting, postoperative pain. Present and past data available to estimate the time when the concept of normal behavior or habits can compare the two together confirmed that the problem or the identification of contradictions. 3. Fixed and variable information on some of the information is fixed, such as the patient's birth date, place, gender is fixed. Some data are variable, such as the patient's body weight, body temperature, blood pressure, food intake, excretion, etc. may change. Variable data should be noted that the dynamic of observation, and in or on a regular basis to collect, record, in order to analyze and judge. (D) data collection methods 1. Methods of data collection methods are mainly four kinds, namely, reading, conversation, observation, measurement. (1) reading, including access to medical records and related records, documents, understand the patient's name, occupation, complaint, examination results, newly diagnosed, health care measures, targeted to make conversation in a driving position. (2) talk to talk to a patient, including asking and listening. Estimated in the care of patients to talk with the main purpose is to collect information on health status of patients in the past, and now the response to disease and the family and social information about the situation, made to establish various types of information required for nursing diagnosis, but also to establish a good nurse patient relationship. Estimated in the conversation while nursing can also be related to the patients for their disease, treatment and care information, give advice, provide emotional and psychological support. Care is estimated to talk not only when the patient was admitted also in the process of care after a continuing basis, to assess the progress of the disease, or give education, guidance and help. Therefore, nurses should have basic knowledge of communication, methods and techniques before they can be more easily accessible to patients, understand the real and timely information, and then type it into the program and used to care. (2) observed for scientific observation is the basic method is to carry out any nursing care activities should have the skills. System, including the use of visual observation, touch, hearing, smell and so a comprehensive understanding of the patient's perceived physical and psychological state. Through the observation of the conversation to verify the information collected and the added benefit of a scientific issue to determine care (Table 23-1) Table 23-1 the main content of patient care and observation of the appearance and functional characteristics of the patient interaction with others the content and process and talk to the visual environment, clothing, eyes, posture modification of gait balance skin complexion lip color, nail shape hair prosthetic tongue mucosa secretion and discharge characteristics of body movement, gestures, eye contact, facial expression response to the families of patients, family friends and relatives of patients attitudes and bed ward unit cleanliness, clothing, appliances, light, clean and tidy condition of the patient is comfortable and convenient living with or without cause infection and disease factors in accidents tactile skin temperature and humidity changes in elastic tension of the pulse of tumor size with or without muscle tenderness of air humidity, cleanliness and quality of goods cardiopulmonary auditory language percussion auscultation bowel sounds cough blood pressure to talk with others, the amount of sound intensity, the specific content about whether the ward noise factors which stimulate the hearing taste smell sputum, urine, feces and vomit special odor odor compounds according to certain nursing observation sequence, commonly used methods, there are two observations; one from head to foot type, ie head, neck, chest, abdomen, spine, limbs, genitals, anus, nerve reflection, communication, environment, the order, to avoid unnecessary duplication and omissions. Second, several large-scale systems by type, from several body systems working, and not from the local to proceed. Usually multi-hospital system will focus on examination of the project by India in the physical examination form, can be checked without missing or duplicate entries. Should be integrated in the use of visual observation, touch, hearing, smell and other perceived `. (4) measurement is through the use of a number of measuring instruments to determine the level of things, the size, frequency, rhythm, volume, etc., to supplement and confirm the information sensory observations. Measurement data, including laboratory results, vital signs, height, weight, urine output and so on. Some quantitative observations can be used as a general measure data, such as the number of cigarettes smoked during the conversation, three meals a day the amount of observed data, and electrocardiographic monitoring. 2. During nursing should pay attention to the following questions is estimated (1) to establish a good relationship between nurses and patients, nurses and patients is conducive to good relations between data collection, especially with the patient's emotions, understanding the relevant information and contribute to mutual understanding of language. (2) to collect information in order to distinguish between primary and secondary general should first estimate the patient's major health problems and issues related to these various situations, and then collect the patient's general health. (3) There are many sources of information for patients is often the main source of information, but do not overlook other sources, such as patient family members, work units of the officers, doctors, medical records and so on. (4) select the appropriate data collection methods should be based on the patient's age, health status and the use of data sources decided to choose which method is most appropriate. Useful information on an item at least two common methods of data collection confirmed. (5) Data to be objective, be it through conversation, observation, or by measuring the data collected must be objective, the nurse on the interpretation of these data can be the basis for further data collection, it must not be the data itself. (6) data collection work is continuing uninterrupted, in the first after the care is estimated, will the information collected on the synthesis, analysis, time often find that some of the gaps, that is not collected omissions To make nursing diagnosis is correct, then return to the patient side to be added to collect data. In the subsequent care process, but also constantly have new information shown, it is timely to estimate. Second, the nursing diagnosis (a) of the definition of nursing diagnosis is the patient's physical and mental health of existing or potential problem description, the problem is within the scope of work in nursing, nurses have the responsibility and have the ability to deal with. Specifically, nursing diagnosis refers to the nurse about, look, who seized medical consultation, through the patient's condition, psychological, family and social situation of the understanding, care and determine the need to adopt means to resolve the core issues, thus the conclusions made . (B) the composition of nursing diagnosis and formula 1. Formed to establish a nursing diagnosis, there should be four basic content areas. (1) diagnosis of the name of an overview of health care and the object description, the diagnostic name, also known as general health problems. (2) defines the name of the definition of a clear diagnosis of the expression of this and other diagnostic for identification. If the definition of oral mucosal changes in oral mucosa of damage. (3) the diagnosis of a variety of relevant factors that can cause problems or the development of the direct effects of the major contributing factors and risk factors. (4) diagnosis based on physical, psychological, spiritual aspects of social performance. 2. Formula nursing diagnosis consists of three parts, known as the PES formula. (1) health problems (Problem), the name of the nursing diagnosis is the individual health status of the existing or potential description. These problems are reflected in changes in health status, but does not indicate the degree of change. (2) the reasons or the factors (Etiology), the related health problems or related factors, or risk factors. Because often refers to the direct factor that causes the problem. Often refers to the relevant factors, factors that cause this problem. (3) disease and physical disorders (Signs and Symptoms), observed in the patient a set of signs and symptoms is often an important feature of health problems. For example, malnutrition, P, S and dietary fat intake too much care about E. Clinical diagnosis is often a problem (or the signs and symptoms) + because (in the specific circumstances or relevant factors, the formula for PE or SE, for example, : \existing symptoms of the patients diagnosed are those that are experiencing at this moment the problem, the patient has shown symptoms, such as \, sleep well, limited mobility and a series of symptoms or signs. 2. potential symptoms of patients the diagnosis is currently no specific symptoms and signs, but with a number of threatened or there are certain risk factors exist, if in the care of not take into account the risk factors, preventive measures are not taken, the patient will be a problem. such as \\exclude the diagnosis of additional information or further confirm the diagnosis. (d) Nursing diagnosis and the difference between medical diagnosis and treatment and diagnosis is linked to a disease, a group of symptoms and signs of the narrative, is a name used to describe the disease causes pathophysiological changes to guide treatment; nursing diagnosis is the patient described as pathological, mental status changes caused by the impact of existing or potential health care problems is to formulate the basis for nursing interventions. nursing diagnosis made by nurses, care is necessary to refer to medical diagnosis diagnosis, understanding the patient's suffering and physical needs, the measures taken to support health care or with doctors, treat disease, promote and restore the health of patients; also in accordance with the patient's individual differences, psychological and social factors of different responses to disease and different characteristics needs to establish a different nursing diagnosis. the same disease may have different nursing diagnosis, different diseases can have similar nursing diagnosis. generally believed that the nursing diagnosis involves three aspects. 1. with the implementation of nursing diagnosis such as doctor's advice, in this context, the role of nurses is to make the doctor's advice in the implementation of treatment programs are accurate, the question on doctor's advice in the context of nurses generally do not need to diagnose and perform a clinical course and treatment response monitoring changes in disease prevention complications, you need to make a nursing diagnosis of nurses. For example, when found that a low blood sugar of diabetes patients have aura symptoms, the nurse should diagnosis \strict record of food intake, clinical symptoms, the doctors provide the basis for adjusting insulin dosage. 2. collaborative nursing diagnosis on the patient's treatment goals often by nurses and doctors work together to complete. such as cerebrospinal fluid of patients \possible \. to prevent a cold, avoid coughing of crack healing. This is a health care cooperation for a common goal --- to prevent intracranial infection process. 3. independence of the nursing diagnosis according to the patients existing or potential physical and mental suffering, or adverse reactions, in within the scope of nursing functions, the nurse has the responsibility to make a diagnosis of the patient's health problems, and to choose nursing measures to promote health or alleviate the condition. limitation and prevention of the negative factors are not conducive to health, including life care, functional training, the nutrition metabolism, excretion function, the rest sleep, awareness of awareness, the emotional behavior and family and social support direction. such as when the patient coughs due to fear of pain or inability to cough up secretions, the nursing diagnosis of \objects, and sputum viscosity, inability to cough up about \to prevent pulmonary complications. independence of the nursing diagnosis is an independent work done by nurses, it is the fundamental difference between the medical diagnosis; and with the cooperation of the nursing diagnosis, have some contact with the medical diagnosis. a patient's medical diagnosis to establish After corresponding with the common and cooperative nature of nursing diagnosis, but this is not absolute, the same medical diagnosis of patients due to physiological, psychological, family, various social factors, the nursing diagnosis may also have different outside. a nursing diagnosis manifestation of the independence of duty nurses, it helps determine the patient care nurse and nursing goals, nursing diagnosis function is to nurse made according to its preventive measures, such as health education, function, bedsore prevention, prevention of complications. also It is made in accordance with the corrective measures, such as time compression of chest tube to help the patient cough to address effectively closed thoracic drainage tube to reduce possible. In short, the nursing diagnosis of patients reflects the physical, psychological and social factors in all aspects of the situation , implies that the patient should receive care, which is a fundamental difference between medical diagnosis Ji You have close ties. (e) writing nursing diagnosis should pay attention to the problem 1. issue a clear, easy to understand. 2. a diagnosis for a Group specific issues. 3. nursing diagnosis must be based on the information collected, obtained after sorting, different patients suffering from the same disease, not necessarily with the same care and diagnosis, patient information to see the situation, there must be sufficient evidence make a diagnosis. 4. to determine the issue is the need to use care and measures to address, mitigate, or monitor, but can not be with the medical aspects related issues. 5. nursing diagnosis should provide direction for the nursing care, so cause or statement of the relevant factors must be detailed, specific, easy to understand. such as \habits \to reduce or resolve the problem. plan is designed to prevent patients from receiving appropriate for his personal care, maintaining the continuity of care, and promote communication and help evaluate the medical staff. (b) content in the planning process, goals should be set up to develop measures. 1. to establish goals of care is the ideal outcome goals. Its purpose is to guide the development of care measures, to measure the effectiveness of measures and practical, this target should have the following characteristics; must be patient-centered, reflecting the the patient's behavior; to be realistic, can be achieved; can be observed and measured, with specific testing standards; have time limits; jointly developed by the nurses and patients. objectives of the sub-term and recent, long-term goal is to take a long time to implemented a wide range; short-term goal is to achieve long-term goal is a specific step or need to address the principal contradiction. such as lower limb fracture patients, its long-term goal is to \walking with crutches the first month \looking forward to the behavior of patients achieving goal is to nurse the patient's specific care programs; is to establish a nursing diagnosis and goal specific implementation plans. focus on the catch into health; to maintain normal function; compensation loss prevention functions; meet basic human needs; to prevent, reduce or limit the adverse reactions. nursing interventions can be divided into dependent, interdependent and independent categories: (1) dependence of the nurses to perform a clinical nursing measure the specific method, which describes the implementation of health measures behavior. such as the doctor's advice, \, physical therapist collaboration. by a nurse to contact your doctor, joint implementation. such as renal failure patients, doctor's orders \calculated with the patient in the class to be the amount of fluid intake, the nurse developed measures: �� intravenous rehydration 30ml / h, the infusion pump control input. �� Oral liquid: 7:30 am-3: 30pm volume 315ml, 240ml by the food intake, 75ml from the medication intake. 3:30 pm-11: 30pm volume 195ml, 120ml 75ml medication intake by food intake. 11:30 pm-7: 30am 100ml total independence of medication intake �� Such nursing care measures designed and implemented entirely by nurses, not medical advice. nurses by virtue of their knowledge, experience, ability, according to nursing diagnosis development; is in areas of responsibility, independent thinking, judge of the measures decided. Example: female patients , 52, duodenal ulcer, complained of insomnia. The collection of information analysis that related to insomnia and daytime sleepiness. nurses according to patient, their own experiences to develop the following measures: �� 7:00 am to 9:00 pm the patient does not sleep; �� walking exercise every day when sleepy; �� sleep before going to bed to help promote the activities of the patient, and feet with warm water, reading newspapers, listening to soft music and relaxation therapy. nursing should possess the following characteristics and composition: the full use of the appropriate resources, including equipment, economic strength and human resources; realistic, reflecting the individual's care; content specific, clear and concise; a patient participation; a scientific theory. To guarantee the correct implementation, the nurse measures should include; date verbs, who is going to perform? What time? should be doing? what to make? where? on some general steps in the measures do not have to write, as a result of special circumstances the patient can not be performed by conventional procedures, it should be in nursing listed. The final content of nursing signatures. An order is a part of the care plan. ordered because the contents are: level of care, diet care, disease observation, basic nursing, check the before and after care, psychological care, management performance maintenance, functional training, health education, symptomatic care, doctor's advice execution. An order should be clear, explicit and designed to fit a proposed patient's care needs should not be stereotyped as normal. IV, Implementation Plan (a) of the definition of implementation is In order to achieve care plan objectives of the measures will be put into action the process. include a variety of nursing activities to address nursing problems, record findings and patient care activities of the reaction. the implementation of the plans or designated others to execute the implementation of active participation of patients . The point is that the implementation process of individual care and behavior, enhancing safety. implementation of the quality of the knowledge of nurses, interpersonal skills and operational level on technical aspects. the case of the implementation process should be recorded at any time by text. (b ) preparation prior to the implementation 1. more familiar with and understand the implementation of the plan on the program for the purpose of each of the measures, requirements, methods and timing should be well aware of to ensure that measures are implemented, and to nursing behavior consistent with the plan. In addition, nurses should understand the theoretical basis of the measures to ensure that science and nursing. familiar with the plan is based on the reading program, refer to the books, or in disease areas of responsibility within the organization group discussion, analysis focused patient's plan. 2. analysis of nursing knowledge and skills needed to analyze the implementation of these measures of nurses needed to care knowledge and technology, if inadequate, should review the books or information, or to other persons for advice. 3. clear may occur complications and care of the implementation of measures against certain patients may have some degree of damage. nurses must be fully expected the incidence of complications, avoid or reduce damage to the patient to ensure patient safety. 4. reasonable arrangement, Science use of time, manpower and resources to implement the timing of care measures and arrangements to be appropriate, and estimate their time to ensure adequate time to complete the implementation of measures to prevent the inappropriate result of fuss. In the arrangement of human responsibility head nurse or head nurse also should ensure that adequate and appropriate support staff to complete the work. Furthermore, we need to consider the necessary equipment ready to improve and create a make patients feel comfortable, safe, and conducive working environment for nurses . (c) implementation process in the implementation phase, the focus of care is to begin implementation of the measures have been developed to implement medical advice, be ordered to achieve the goal, to solve the problem. in the implementation of nursing must pay attention to both operating according to standardized implementation of each routine measures, and pay attention to each patient based on physiological and psychological characteristics of individual implementation of care. in the implementation of health education needed in order to meet the learning needs of patients. content, including access to knowledge, learning technique, individual psychological and emotional changes state. implementation is estimated that diagnosis, and planning the stage extension, estimated to be alert to the patient's physical, mental state, tolerance of the patients on the measures, response and effect of efforts to make nursing care to meet patient's physical, psychological needs, promote disease rehabilitation. the responsibility of nurses is to implement the plan to key personnel, must also rely on each class auxiliary nurses, and patients and their families to obtain the cooperation and support, working closely with the medical care activities, although each has its content, but the overall goal is the same and, therefore, the implementation of the medical staff should share information and close coordination. in the implementation, responsibility for nursing care activities take a variety of results and patient response to a complete and accurate written records, the nursing care in the course of medical records. to reflect the care and results, to prepare for the evaluation. Fifth, the evaluation stage (a) of the definition of evaluation is the health of the patient's care with the previously identified targets in a planned and systematic comparison process. evaluation is run through the whole process of care activities, the initial estimation stage the patient information to evaluate the basic data with which to compare; nursing diagnosis is the basis for evaluation; nursing goal was to evaluate the standards. (b) Purpose The purpose of evaluation is to determine the most important health status of patients to the goal of progress. but also to determine the formulation and implementation of nursing process effects. in determining the health status of patients improved, it is also evaluating quality of care and to promote improved care process. (c) content evaluation system includes organizational assessment , nursing assessment and care program results in three aspects. these three aspects of the evaluation are very important, but the most important effect is the evaluation of nursing care, which provides nursing care and the effectiveness of the powerful state of proof; nursing program evaluation is to evaluate the care of nurses in the implementation of each step in the behavior program correctness, is conducive to care and to obtain the best results; organization and management assessment and the use of nursing process and nursing care be organized to ensure the effectiveness. So is the relationship among them, mutual influence, mutual restraint.
