Unit 4 Nursing Process 四川大学华西第二医院 彭文涛 E-mail：670537614@qq.com

Objectives List and briefly describe the 5 steps of nursing process ★ State the purposes of the nursing process Explain how Maslow’s hierarchy of needs in nursing practice

Vocabulary（掌握） assessment 评估 diagnosis 诊断 planning 计划 Intervention/implementation 实施 evaluation 评价 priorities of care 护理的优先项目 individualized care 个性化护理 3

Vocabulary（熟悉） physical examination 体格检查 review of record 病历回顾 inspection 望诊 palpation 触诊 percussion 叩诊 auscultation 听诊 psychological 心理的 physiologic 生理的 4

Vocabulary（了解） physical needs 生理的需要 safety and security 安全的需要 needs for love and belonging 爱与归属的需要 needs for esteem and self-esteem 尊重和被尊重的需要 self-actualization needs 自我实现的需要 5

Vocabulary（了解） Ineffective breathing pattern 清理呼吸道无效 fluid volume deficit 体液不足 high risk for injury 有受伤的危险 parental role conflict and social isolation 父母角色冲突和社交隔离 powerlessness and ineffective individual coping 无能为力感和个人应对无效 altered growth and development 生长发育异常 spiritual distress 精神困扰 6

What’s nursing process Define : A method for organizing nursing actions involving both intellectual and physical activities Intellectual adj . 智力的； 有才智的 In+tel (l) (说) +lect (讲)+ual →讲话井井有条→有智力的 e.g. : High levels of lead could damage the intellectual  development of children Physi-,physio- 生理学、躯体的，物理，自然的 +cist（专家） physicist 物理学家 +o+logy(学科）physiology 生理学 +o+therapy(治疗）physiotherapy 物理治疗法

What’s nursing process Evaluation Assessment Planning Intervention Diagnosis

What’s nursing process A method for organizing nursing actions involving both intellectual and physical activities It is a systematic process an d requires problem solving, critical thinking , decision-making, and a substantial knowledge basis to identify the status of the client problem solving 解决问题 critical thinking 评判性思维 decision-making 决策

High quality nursing care

Carry out the plan of care Develop nursing strategies The Purposes Identify health problems Guide nursing care Carry out the plan of care Evaluate the results Develop nursing strategies

STEP 1 : Assessment Definition : collect the data to formulate nursing diagnosis Observation 观察 Interviewing 面谈 Physical examination ★体格检查 Review of records回顾病史 skills

Observation Involves the use of sense of sight 、smell、hearing、touch

Interview Tool :Nursing history e.g: How are you feeling today ? What's the matter with you ? Past medical history 既往史 Present medical history 现病史 Chief complaint 主诉 How long have you been like this?像这样有多久了

Review of records ↙ ↙ ↙ ↙ History hypertension Hyperlipemia Glycuresis 高血压 高血脂 ↙ ↙ Glycuresis Tachycardia 糖尿病 心动过速 Nutrition A review of both current and previous nursing records

Physical examination → ↙ ↙ → Stethoscope n .听诊器 Stethoscopic adj .派生词 gastroscope n.胃镜 colonoscope n.肠镜 microscope n.显微镜 Steth:胸 Scope:审视 → ↙ ↙ → Steth- o -scope e.g. :The stethoscope is a medical instrument

Physical examination Mal-糟糕，坏，错误 +nutrition malnutrition 营养不良 Over-剩下的，未用的 +nutrition overnutrition 营养过剩 eg:Socio-economic drivers of overnutrition in China

Physical examination ↙ → ↙ → ↙ Hematomanometer n . 血压计 Hypertension n. 高血压   Hypotension n.低血压 tension:情绪 Hyperventilate V.过度通气 Hypodermic n.皮下注射 hypoallergenic n.低变应原 Hyper:亢奋的 ↙ → ↙ → Hypo/Hyper tension ↙ Hypo:低 倾向于，预先安排 e.g. :His lifestyle predisposed him to hypertension

Physical examination cardio-心脏的 +logist(专家）cardiologist心脏病医生/学家 +gram(图表） cardiogram 心电图 +logy(学科）cardiology 心脏病学  eg:There's just a little strain showing on your cardiogram

Physical examination → ↙ ↙ → Thermometer n.温度计 Clinical thermometer n.体温计 Thermo:热 Meter：测量仪表 → Hematomanometer n.血压计 Baresthsiometer n.压力计 ↙ ↙ → Thermo- meter e.g. : Please put the thermometer under your armpit

Physical examination ion ＋ 视 触 叩 听 视 触 叩 听 Inspect Palpate Percuss Auscultate (V) ＋ ion Inspection Palpation Percussion Auscultation (N) e.g. :The skills used in physical examination are inspection , palpation ,percussion ,and auscultation

STEP 2:nursing diagnosis Definition : It’s a statement of an actual or potential health problems that can be treated by nurses (Problem+cause) ~Ineffective breathing pattern ~Fluid volume deficit ~High risk for injury ~Anxiety 、dysuria…......

Associated with infection of incision nursing diagnosis Label : definition + defining characteristics + related factor e.g. Label :hyperthermia Definition :Temperature is above normal range Defining characteristics : Major :beyond 37.8℃ Mino：rubeosis(潮红) Related factor : Associated with infection of incision

Diagnosis → ↙ ↙ → e.g. : The new drug was ineffective Ineffective adj . 无效的、低效率的 Ineffectively adv . 无效地、无能力地 Ineffectiveness n. 无效果 Effective:有效 → In:无 、否定 Inadequate adj . 不充分 Incorrect adj. 不正确的 ↙ ↙ → In effective e.g. : The new drug was ineffective

diagnosis ↙ ↙ ↙ → → Fluid volume deficit 体液不足 Fluid volume deficit Cardiac output deficit 心排出量不足 Fluid volume deficit → e.g. : He has the risk for fluid volume deficit Tachycardia 心动过速 bradycardia 心动过缓 Tachy-:fast + pnea tachypnea 呼吸急促 brady-:slow +pnea bradypnea 呼吸缓慢

diagnosis → ↙ ↙ → Dysuria 排尿困难 Urinate vi. 排尿 Urine n.尿、小便 urination n .排尿 Dys: 困难 uria: 小便 → Dyspnea n. 呼吸困难 Dysprognosis n. 预后不良 ↙ ↙ → dys uria e.g. : Objectives to investigate how to prevent the dysuria after supra’pubic prosta’tectomy

So many problems， what should I Consider first

STEP 3: planning Definition :identify goals and select nursing actions to resolve a client’s health problems. The nurse lists the client’s problems and then determines which ones require the most urgent attention Nurses have adopted Maslow’s hierarchy of needs as a tool for setting priorities of care

Maslow’s hierarchy Self-actualization Esteem and self esteem Spiritual distress Self-actualization Esteem and self esteem Love and belonging Safety and security physiologic Fifth Fourth level Third level Second level First level Powerlessness Social isolation anxiety 基本生存

Abraham H.Maslow A H. Maslow (马斯洛)： American social psychologist 美国社会心理学家 Personality theorists 人格理论家 Psychology n.心理学 ist:专家 → → Psycholog ist 1908 - 1970 physicist ：物理学家 scientist：科学家 e.g. :He is now a consultant psychologist with a major London hospital

SEPT4 :intervention ↙ Coordinating 协调 Supervising 监督 Implementing执行 Definition : execute the plans established for the client ↙ 已建立的、已设立的 Coordinating 协调 Supervising 监督 Implementing执行 Each nurse caring for a client promotes continuity of care by implementing the established care plan

NO 5: evaluation Definition :determine whether the desired outcomes have been achieved Nurses Clients Misidentified Unrealistic Ineffective New problem complications satisfaction time recovery ability Promote health

STEP 5: evaluation Pain relief or not ? patient Hypothermia or not ? Free from infection or not ? Effective cough or not ? Malnutrition or not ? Hypothermia 低体温 Malnutrition 营养失调 Infection 感染 Cough 咳嗽

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