Unit 4 Nursing Process

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

2. 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

3. Vocabulary（掌握）

4. Vocabulary（熟悉）

5. Vocabulary（了解）

6. Vocabulary（了解）

7. What’s nursing process • Define : A method for organizing nursing actions involving both intellectualand 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

8. What’s nursing process Evaluation Assessment Planning Intervention Diagnosis

9. 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

10. High quality nursing care

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

12. 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

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

14. 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

15. Review of records History ↙ ↙ hypertension Hyperlipemia 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

16. 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 Scope:审视 Steth:胸 → ↙ ↙ → Steth- o -scope e.g. :The stethoscope is a medical instrument

17. 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

18. 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

19. 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

20. 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

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

22. 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…......

23. 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

24. Diagnosis 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 wasineffective

25. diagnosis Fluid volume deficit体液不足 volume:体积 deficit:不足 Fluid :液体 ↙ ↙ ↙ → 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

26. 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

27. So many problems， what should I Consider first

28. 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

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

30. 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 ist:专家 Psychology n.心理学 → → 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

31. SEPT4 :intervention 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

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

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

35. Thank You!