護理過程是護理人員用來規劃和提供個別化照護的系統性、以病人為中心的方法。它是專業護理實務的基礎,確保每位病人都能接受符合其特定需求和情況的照護。
護理過程包含五個相互關聯的步驟。首先是評估,收集病人的健康資料。接著是診斷,識別病人的健康問題。然後制定計劃,設定目標和干預措施。第四步是執行,實施照護計劃。最後是評值,評估照護成效並持續改進。這是一個循環的過程。
評估是護理過程的第一步,也是最重要的基礎。護理人員需要全面收集病人的健康資料,包括主觀資料如病人的感受和主訴,以及客觀資料如生命徵象、身體檢查發現等。這個階段還包括回顧病史和評估病人的心理社會狀況。
在診斷階段,護理人員分析收集到的資料,識別病人的健康問題,並確立適當的護理診斷。接著在計劃階段,根據護理診斷設定預期成果和護理目標,並選擇最適合的護理干預措施。這兩個階段為後續的護理實施奠定重要基礎。
執行階段是將護理計劃付諸實行的過程,護理人員實施各種干預措施,與病人及家屬溝通,並詳細記錄護理活動。評值階段則評估護理目標的達成情況,並根據結果修正護理計劃。護理過程是一個持續循環的動態過程,確保照護品質的不斷提升。
The nursing process consists of five interconnected steps. First is assessment, collecting patient health data. Next is diagnosis, identifying patient health problems. Then planning, setting goals and interventions. Fourth is implementation, carrying out the care plan. Finally evaluation, assessing care effectiveness and continuous improvement. This is a cyclical process.
Assessment is the first step of the nursing process and the most important foundation. Nurses need to comprehensively collect patient health data, including subjective data such as patient feelings and chief complaints, as well as objective data such as vital signs and physical examination findings. This stage also includes reviewing medical history and assessing the patient's psychosocial status.
In the diagnosis phase, nurses analyze collected data, identify patient health problems, and establish appropriate nursing diagnoses. Then in the planning phase, based on nursing diagnoses, they set expected outcomes and nursing goals, and select the most suitable nursing interventions. These two phases lay an important foundation for subsequent nursing implementation.
The implementation phase is the process of putting the nursing plan into action. Nurses implement various interventions, communicate with patients and families, and document nursing activities in detail. The evaluation phase assesses the achievement of nursing goals and modifies the nursing plan based on results. The nursing process is a continuous cyclical dynamic process that ensures continuous improvement of care quality.