Nursing plan of thyroidectomy
First of all, pain
correlative factor
1, the overall system is unbalanced.
2. Stay in bed for a long time.
3. cough.
Nursing goal
1, the patient has the ability to endure pain.
2. The patient complained that the pain disappeared or eased.
3. Patients/family members can take corresponding measures to relieve pain.
Nursing measures
1, teaching patients how to protect the wound/drainage tube.
2. According to the patient's tolerance to pain, plan the range of activities.
3. If necessary, give painkillers before the activity/operation.
4, record the patient's response to analgesic measures or painkillers.
Second, there is a danger of suffocation:
correlative factor
1, cognitive impairment.
2. Improper safety measures.
3. Lack of safety education.
4, respiratory muscle spasm/fatigue.
Nursing the target patient not to suffocate.
Nursing measures
1, give oxygen according to the doctor's advice, and adjust the oxygen flow according to the condition.
2. Suck sputum when necessary.
3. Observe whether there is cyanosis of lips, nervousness, sweating and dyspnea, and inform the doctor immediately if there is any.
4. Encourage patients to actively expectorate and keep the respiratory tract unobstructed.
Third, there is a risk of injury.
Related factors 1, change of consciousness. 2. Fatigue/weakness.
Nursing goal
1, the patient was not injured.
2. The patient complained that the symptoms of discomfort were relieved or disappeared.
Nursing measures
1. When dizziness/vertigo occurs, ask the patient to stay in bed.
2. Arrange the patient in the room near the nurse station and teach the patient to use the walkie-talkie.
3. Keep daily necessities at your fingertips for easy access.
Question 2: How do patients with high fever write a good nursing plan for this medical record? You should learn the nursing procedures for patients with high fever.
Question 3: In the nursing plan, the expected goal is to state 40 points in the nursing plan, and the expected goal is to state the degree to which the patient's health should be achieved.
Nursing plan is to convey the specific problems of nursing objects to nursing staff and make decisions on how to solve the existing problems, and the nursing measures listed in it are used as the guidance and evaluation basis of nursing activities. Generally divided into three steps:
1, nursing diagnosis statement:
Prioritize the listed nursing diagnoses (or problems) according to their importance and urgency. The general principle is to have something first, then something urgent, and then something slow, so that nurses can work in a planned way according to light, heavy, slow and urgent.
2, set the expected goal:
Nursing goals are achievable, measurable and observable behavioral goals of patients and their families. Can guide nurses to guide, prevent and eliminate patients' health problems. It is also one of the bases for evaluation.
3, formulate nursing measures:
Nursing intervention is a specific nursing activity to prevent, alleviate and eliminate patients' health problems and help patients achieve their expected goals. These measures can be called nilstanding order, and the elements are: ① date and time. ② Behavioral verbs. ③ Specific contents and methods. ④ Signature of the planner.
State nursing diagnosis
1, generally can be arranged in three orders.
(1) High priority problem.
Refers to life-threatening problems that need immediate action to solve, such as ineffective respiratory tract cleaning, suffocation danger, despair, tissue perfusion changes, etc.
(2) Medium priority problem.
It refers to problems that do not directly threaten patients' lives, but can also lead to unhealthy body or emotional changes, such as premonitory sadness, activity intolerance, chronic pain, skin integrity damage, infection risk, etc.
(3) Low priority problem.
It refers to the problems that occur when people cope with development and life changes, such as malnutrition: higher than physical needs, defective entertainment ability and so on.
In addition, potential problems may not be the first consideration, and patients often don't realize their importance. Nurses should use their theoretical knowledge and clinical experience to comprehensively evaluate patients. For example, patients with tumors and hematological diseases have great opportunities and hazards of potential infection, so this problem should be considered first.
Set expected goals
1, classification of nursing objectives
(1) Short-term goal
It refers to the goal that patients can achieve within one week, and is suitable for patients with acute, severe and rapid changes.
(2) Long-term goals.
Refers to more than a week, even a few months, suitable for patients with long course of disease and recovery period. Such as patients who have been in bed for a long time and have been treated with drugs for a long time.
2. Statement of nursing objectives
(1) The subject refers to the patient or any part of the patient, otherwise it is the patient.
2) Predicate refers to the action that the patient will complete, which must be explained by behavioral verbs (such as speaking, describing, implementing, performing, showing, etc.). For example, patients can talk about anxious psychological activities.
(3) the specific content and time, such as getting out of bed for bedside activities within 3 days, can not have bedsores during hospitalization.
(4) How do patients meet the standards ① Nurses make patients meet the standards through their own efforts. ② Cooperation between doctors and nurses. (3) Nurses, patients and family members * * * cooperate.
3. Matters needing attention in setting nursing goals
(1) The nursing goal is the expected goal that patients should achieve through nursing, not the nursing action itself. If the patient can describe the purpose and significance of preoperative preparation within 3 days, the subject of this goal is the patient, and the goal is what the patient wants to achieve. If it is to let patients understand the purpose and significance of preoperative preparation, the subject of this sentence is nurse, purpose >>
Question 4: How to write the work plan of nursing department? The year 200 is a year in which the national health system continues to deepen its reform. Under the attention and direct leadership of the dean, all the nursing staff successfully completed all the nursing work assigned by the hospital leaders and completed more than 90% of the nursing plan in 2000. The work is summarized as follows:
First, seriously implement the rules and regulations.
Strict implementation of rules and regulations is the fundamental guarantee to improve nursing quality and ensure medical safety.
1, the nursing department reiterated the responsibilities of nursing staff at all levels, clarified the post responsibility system and nursing work system for nurses on duty and visiting nurses, and put an end to the bad phenomenon of patients changing infusion bottles and pulling needles by themselves.
2, adhere to the inspection system:
(1) requires the class to check the doctor's advice, and the head nurse participates in the total check 1-2 times a week and records it;
(2) Nursing operation requires three checks and seven pairs;
(3) Insist on filling in the infusion card, and no major nursing mistakes have occurred in the past year.
3, conscientiously implement the orthopedic nursing routine and microsurgical nursing routine, adhere to fill in all kinds of information and data register, equipped with five types of surgical disposal tray.
4, adhere to the bedside shift system and morning care, to prevent the occurrence of complications.
Second, improve the management level of head nurses.
1. Adhere to the record and assessment of the head nurse's handbook: require the head nurse's handbook to be submitted to the nursing department for assessment before the 5th day of each month, and supervise the implementation and monitor the implementation effect according to the annual plan, seasonal arrangement and monthly plan formulated by the head nurse, and require the head nurse to summarize the monthly work so as to sum up experience and carry out the work.
2. Adhere to the regular meeting system of head nurses: according to the requirements of grade hospitals, hold a regular meeting of head nurses once a week, with the contents as follows: arrange the focus of this week's work, summarize the advantages and disadvantages of last week's work, put forward corresponding rectification measures, feed back the nursing quality control inspection to the head nurses, and learn the relevant materials of head nurses' management.
3, check the quality of nursing every month, and timely feedback, and constantly improve the management level of the head nurse.
4. Organize head nurses to study abroad, learn from the advanced experience of brother units, and expand their knowledge: at the end of May, head nurses from three wards were selected to participate in the new international nursing progress class, and reported to all nurses after the study.
Third, strengthen the construction of medical ethics of nursing staff.
1, continue to carry out the code of conduct for nurses, and carry out 50 civilized expressions for nurses in daily work.
2. Organize all nurses to attend etiquette training in Wenling Hotel and Wanchang Hotel in June, 165438+ 10 respectively.
3. Continue to carry out health education and issue satisfaction questionnaires to inpatients. The results of satisfaction surveys (regular or irregular evaluations) are all above 95%. In addition, corrective measures were put forward for the problems existing in the satisfaction survey, and the best nurses were selected.
4, the department held a symposium on a regular basis every month, solicit opinions from patients, to meet the demands of patients to the maximum extent.
5. Carry out pre-job professional ethics education, rules and regulations, nurse code of conduct education and basic nursing knowledge, specialist knowledge and nursing technology operation assessment for newly assigned nurses, and those who pass the examination will be given posts.
Fourth, improve the professional quality of nursing staff.
1. Conduct "three basics" training for on-the-job personnel and organize theoretical examinations.
2, cooperate with the medical department, hire experts to teach, teach orthopedics, internal medicine, surgery knowledge, in order to improve professional knowledge.
3. Each department asks questions 1-2 times a week in the morning, and the content is basic theoretical knowledge and orthopedic knowledge.
4. A nursing technical operation competition (aseptic operation) was held on March 8th Women's Day, and the first prize (,second prize (,Tang,) and third prize () were awarded respectively.
5.65438+At the beginning of February, the nursing department conducted a nursing technical operation examination for the nurses in the whole hospital:
Examination of nurses in ward: intravenous infusion and oxygen inhalation; Examination of nurses in emergency room: cardiopulmonary resuscitation, oxygen inhalation and gastric lavage; Examination of nurses in operating room: intravenous infusion and aseptic operation.
6, strengthen the nursing of critically ill patients, adhere to the bedside succession system and morning care.
7. Insist on nursing rounds: conduct nursing rounds in three wards in turn every month to discuss nursing diagnosis and nursing measures to improve professional quality.
8.165438+1October 9-June, 9 nurses who entered the hospital this year were given pre-job training on basic nursing and specialized nursing knowledge, and each head nurse was organized to have a class to improve their teaching ability.
9. There are 5 nurses in the whole hospital who take the self-taught examination for nursing specialty and 3 nurses who take the correspondence course for nursing specialty.
Five, strengthen the management of hospital infection.
1, strictly implement the ... >>
Question 5: How to make a nursing plan for critically ill patients 1) Closely observe vital signs and conscious state, and make detailed records.
2) Keep the respiratory tract unobstructed, and the comatose patient's head leans to one side and often sucks respiratory secretions.
3) Strengthen life nursing and prevent complications. ① Pay attention to nutrition; (2) take good care of your mouth and keep it clean; ③ Do skin care to prevent bedsore; ④ Patients whose eyelids cannot be closed should be covered with erythromycin ointment or vaseline gauze to protect the cornea; ⑤ Keep the defecation unobstructed, and handle any abnormality in time.
4) Pay attention to safety, lose consciousness and delirium, and encourage patients to use protective equipment to prevent falls.
Question 6: The core content of nursing plan 1, personnel planning
2, personnel selection
3. Personnel development
4. Training and education
Question 7: How to write the nursing plan for chest tightness? Pelvic inflammatory disease refers to inflammation of female upper reproductive tract and its surrounding tissues, mainly including endometritis, fallopian tube, fallopian tube ovarian abscess and pelvic peritonitis. Pelvic inflammatory disease can be treated with combination of traditional Chinese and western medicine. According to the symptoms of patients, the treatment methods of clearing away heat and toxic materials, promoting blood circulation and removing blood stasis were adopted, combined with western medicines with high efficiency. Treatment must be adhered to. If the symptoms disappear, don't take any more drugs, which may easily lead to recurrence or even chronic pelvic inflammatory disease. So the treatment must be thorough.
Question 8: The difference between nursing plan and nursing medical record Nursing medical record: In the clinical application of nursing procedure, the patient's health information, nursing diagnosis, nursing objectives, nursing measures, nursing records and effect evaluation should be recorded in written form to form a nursing medical record. Nursing plan: based on nursing diagnosis, design a dynamic decision-making process on how to meet patients' needs, increase patients' comfort, maintain and promote patients' functions and promote patients' rehabilitation.