2. Special symptoms and signs; In the nursing plan, it is often one of the nursing goals to relieve or eliminate the symptoms and signs that basically affect the health status of patients. Whether these goals have been achieved can be evaluated by direct observation, conversation with patients and examination of medical records.
3. knowledge; Nursing determines the specialized knowledge that patients should acquire after health education.
4. Operational skills: This evaluation is often done through direct observation, and nurses can compare the observed patient's operation with the behavior described in the goal.
5. Psychological and emotional aspects; The emotions and psychology experienced by patients are subjective and usually difficult to measure. The general patient's psychology and emotions are indirectly reflected through his behavior. Nurses should pay attention to the information provided by other medical staff through informal conversation, medical record discussion, shift report, reading various observation records and directly observing the patient's expression, posture, tone and language information.
Extended data
evaluation sheet
1. Nursing rounds: Nursing rounds are one of the most basic, important and frequent nursing activities to evaluate the implementation effect of nursing procedures.
2. Nursing consultation; The consultation targets are critically ill inpatients, emergency patients, patients after major surgery or patients receiving new technologies, new therapies and new operations, as well as patients with complicated conditions.
3. Discharged nursing case discussion: Discharged nursing case discussion is a form of reviewing the implementation of nursing procedures. It is the overall evaluation of the whole nursing process after the patient leaves the hospital.
4. Evaluate the correctness of each walk. Nursing records should be evaluated in time during nursing and retrospectively after patients are discharged from hospital. To implement nursing procedure, it is necessary to establish a quality evaluation system of nursing medical records.
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