A. Check the information
B. Collecting information
C. Information analysis
D. Organizing information
E. recording information area
Nursing evaluation is the first step, which refers to collecting and sorting out the physical, psychological and social health data of the clients, so as to find and confirm the health problems of the clients.
Nursing diagnosis: it is to determine the nursing problems of the clients on the basis of evaluation, and list the nursing diagnosis to describe the health problems of the clients.
Nursing plan: it is to make a decision on how to solve the health problems involved in nursing diagnosis, including arranging the order of nursing diagnosis, determining the expected goal, formulating nursing measures, writing nursing plan, etc.
Nursing implementation: it is the process of implementing nursing measures according to the nursing plan, which achieves the expected goal of nursing.
Nursing evaluation: it is to compare the client's response to nursing with the expected goal, and evaluate the effect after the implementation of the nursing plan according to whether the expected goal is achieved. When necessary, we should re-evaluate the health status of customers and introduce the next nursing procedure cycle.
Matters needing attention are to determine the customer's nursing problems on the basis of evaluation, and list the nursing diagnosis to describe the customer's health problems.
The patient himself is the main source of health information;
1. Family members of the nursing object or family members closely related to the nursing object. When the nursing object is infants, critically ill or insane, their family members and closely related people become the main sources of information.
2. Other health care personnel, doctors, nutritionists and psychologists. Medical records and various inspection reports. Medical and nursing literature.