Mental and emotional state: patients' understanding of disease and health, mental and emotional state, personality type, perception and recognition ability, patients' reaction to stress, views on their own status quo and self-image concept.
Reproductive system: sexual function and its changes. Female patients should ask about menstrual history, delivery history and family planning.
Environmental conditions: whether the patient feels safe, and analyze whether safety protection measures such as bed bars are needed according to the patient's age and mental condition; Whether there are environmental factors of cross infection.
Sensory state: vision; Whether there is visual impairment or even blindness, diplopia or hallucination. Hearing: whether you have hearing impairment or deafness, whether you can hear ordinary sounds clearly, whether you have problems with one or both ears, tinnitus, auditory hallucinations, etc. Smell: Is there a distinctive sense of smell? Nursing evaluation of touch: various feelings of pain, stimulation and touch. Taste: whether the taste is complete or not, and whether the simplest and most basic taste exists.
Evaluation method:
1, systematic observation; In other words, the patient's information is obtained by using the senses such as vision, hearing, smell, taste and touch. Observation is the basic method of scientific work, and the first meeting between nurses and patients is the beginning of observation.
Such as the patient's appearance, gait, mental state, reaction, etc. ; During the patient's hospitalization, the evaluation of nursing staff and the evaluation of the effect after the implementation of measures depend on systematic, continuous and meticulous observation. Therefore, nurses should have keen observation, be good at capturing every subtle change of patients, and selectively collect information related to patients' health problems.
2. talk; Conversation is a special way of interpersonal communication. By talking with patients or their families and friends, we can get the information needed for nursing diagnosis. Conversations can be divided into formal conversations and informal conversations. Formal conversation refers to informing patients in advance and having a purposeful and planned conversation.
For example, asking about medical history after admission is to collect information according to predetermined items and contents. Informal conversation refers to the conversation between nurses and patients in daily rounds, treatment and nursing. At this time, the patient will feel natural and relaxed, which may be considered as a kind of small talk, but the nurse can collect more real information from the patient from this conversation. Different communication methods should be adopted according to patients' different ages, occupations and educational levels.
3. Nursing physical examination: On the basis of mastering physical examination skills such as looking, touching, knocking, listening and smelling, these physical examination skills are used to collect physiological data related to nursing, and the physical examination related to pathophysiological diagnosis should be completed by doctors.
4. Access to records: including the patient's medical records, various nursing records and related documents.