Question 1: What should be written in the care plan? What is the format? Here are a few sample plans I found for your reference only!

Thyroidectomy nursing plan

1. Pain

Related factors

1. Overall system imbalance.

2. Long-term bed rest.

3. Cough.

Nursing goals

1. The patient has the ability to tolerate pain.

2. The patient reports that the pain disappears or is reduced.

3. Patients/family members can take appropriate measures to relieve pain.

Nursing measures

1. Teach the patient how to protect the wound/drainage tube.

2. Plan the range of activities based on the patient's ability to tolerate pain.

3. If necessary, give analgesics before activities/operations.

4. Record the patient's response to pain relief measures or analgesics.

2. Risk of suffocation:

Related factors

1. Cognitive and perceptual impairment.

2. Improper safety measures.

3. Lack of safety education.

4. Respiratory muscle spasm/weakness.

Care to prevent the patient from suffocating.

Nursing measures

1. Give oxygen as directed by the doctor, and adjust the oxygen flow according to the condition.

2. Suction sputum when necessary.

3. Observe for cyanosis of the lips and face, mental stress, profuse sweating, and difficulty breathing. If any, please notify the doctor immediately.

4. Encourage patients to actively expel sputum and keep the respiratory tract open.

3. Risk of injury

Related factors 1. Change in consciousness. 2. Fatigue/weakness.

Nursing goals

1. The patient is not injured.

2. The patient complains that the discomfort symptoms are reduced or disappeared.

Nursing measures

1. When dizziness/vertigo occurs, instruct the patient to rest in bed.

2. Place the patient in a room close to the nurse's station, and teach the patient how to use the intercom.

3. Keep daily necessities within easy reach for easy access.

Question 2: How to write the nursing plan for patients with high fever in this medical record? Should you have learned the routine care of patients with high fever?

Question 3: In the nursing plan, the expected goal is stated 40 points In the nursing plan, the expected goal states the extent to which the patient's health status should be achieved

Nursing care plan is to convey to the nursing staff the specific problems of the care object and how to solve them. Make decisions on problems, and the nursing measures listed in it serve as guidance and evaluation basis for nursing activities. Generally divided into 3 steps:

1. State the nursing diagnosis:

Prioritize the listed nursing diagnoses (or problems) according to their importance and urgency. The general principle is to put the existing ones first and then the potential ones, and first the urgent ones and then the slow ones, so that the nursing staff can work in a planned way according to the severity, severity, slowness and urgency.

2. Set expected goals:

Nursing goals (Nursing Goals) are achievable, measurable, and observable patient behavior goals for patients and their families. Can guide nursing staff to guide, prevent, and eliminate patients' health problems. It is also one of the basis for evaluation.

3. Formulate nursing measures:

Nursing Interventions are specific nursing activities that prevent, alleviate, and eliminate patient health problems and assist patients in achieving expected goals. These measures can be called nursing orders (NilrSing order), and the components are: ① Date and time. ②Action verb. ③Specific content and methods. ④Planner’s signature.

State the nursing diagnosis

1. Generally, they can be arranged in 3 orders.

(1) High-Priority Problems.

Refers to problems that are life-threatening and require immediate action to solve, such as ineffectiveness in clearing the respiratory tract, risk of suffocation, despair, changes in tissue perfusion, etc.

(2) Medium-priority problems.

It refers to problems that, although not directly threatening the patient’s life, can also cause physical ill-health or emotional changes, such as premonition of sadness, inability to move, chronic pain, damaged skin integrity, There is a risk of infection, etc.

(3) Low-Priority Problems.

It refers to the problems that arise when people cope with development and life changes, such as malnutrition: higher than body requirements, recreational ability defects, etc.

In addition, related potential problems are not necessarily the first to be considered. Patients are often unaware of their importance. Nursing staff should use their own theoretical knowledge and clinical practice experience to comprehensively evaluate patients. For example, patients with tumors and hematological diseases have great chances and harms of potential infection, so this issue should be taken into consideration first.

Set expected goals

1. Classification of nursing goals

(1) Short-term goals (Short-term goals)

Refers to The goal that patients can achieve within a week is suitable for patients whose condition is acute, severe, and changes rapidly.

(2) Long-term goals (Long-term goals)

Refers to more than a week or even several months, suitable for patients with long disease course and recovery period. Such as patients who are bedridden for a long time and who receive long-term drug treatment.

2. Statement of nursing goals

(1) The subject refers to the patient or any part of the patient. If not specified, it is the patient.

2) The predicate refers to the action that the patient will complete, which must be described with action verbs (such as speaking, narrating, executing, performing, showing, etc.). For example, the patient can describe anxious psychological activities.

(3) Specific content and time, such as getting out of bed within 3 days to perform bedside activities, and no bedsores occurring during hospitalization, etc.

(4) How the patient reaches the standard ①Nursing staff make the patient reach the standard through their own efforts. ② Medical and nursing cooperation. ③Nurses, patients, and family members collaborate together.

3. Precautions for formulating nursing goals

(1) Nursing goals are the expected goals that the patient should achieve through nursing methods, rather than the nursing actions themselves. If the patient can describe the purpose and significance of preoperative preparation within 3 days, the subject in this goal is the patient, and the goal is what the patient wants to achieve. If it is to make the patient understand the purpose and significance of preoperative preparation, the subject of this sentence is the nurse, and the purpose... >>

Question 4: How to write the work plan of the nursing department in 200*? In a year when the health system continued to deepen its reform, all nursing staff, under the attention and direct leadership of the dean, adhered to the service tenet of "everything is patient-centered and everything is for the patient" and successfully completed various nursing tasks assigned by the hospital leaders. Work, more than 90% of the 200* annual nursing plan has been completed. The work situation is summarized as follows:

1. Conscientiously implement various rules and regulations

Strict implementation of rules and regulations is to improve the quality of nursing , to ensure the fundamental guarantee of safe medical treatment.

1. The Nursing Department reiterated the responsibilities of nursing staff at all levels and clarified the responsibility system and nursing work system for various positions. For example, responsible nurses and circulating nurses should perform their duties to prevent patients from changing their own sling bottles. The undesirable phenomenon of self-pulling needles.

2. Adhere to the check-up system:

(1) Require doctors’ orders to be checked every shift, with the head nurse participating in the total check 1-2 times a week and keeping records;

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(2) Three checks and seven pairs are required during nursing operations;

(3) Persistence in filling in the infusion card, no major nursing errors have occurred in the past year.

3. Conscientiously implement orthopedic nursing routines and microsurgery nursing routines, insist on filling in various information data registration books, and equip five operation trays.

4. Adhere to the bedside handover system and morning care to prevent complications.

2. Improve the management level of the head nurse

1. Adhere to the recording and assessment of the head nurse’s handbook: The head nurse’s handbook is required to be submitted to the nursing department for assessment before the 5th of each month, and the head nurse’s handbook shall be submitted to the nursing department for assessment according to the nurse’s manual. The annual plan, quarterly arrangement, and monthly plan that are suitable for the department are specially formulated to focus on supervising the implementation and monitoring the implementation effect. The head nurse is required to make a brief summary of the monthly work to facilitate summarizing experience and carrying out work.

2. Adhere to the head nurse regular meeting system: according to the requirements of the graded hospital, a regular meeting of the head nurse is held once a week. The content is: arrange the focus of this week's work, summarize the advantages and disadvantages of last week's work, and propose corresponding rectification measures, feedback on the nursing quality control inspection situation to each head nurse, and learn relevant information about head nurse management.

3. Check the quality of nursing care every month and provide timely feedback to continuously improve the management level of the head nurse.

4. Organize head nurses to go out to study and visit, learn from the advanced experience of fraternal units, and expand their knowledge: At the end of May, the head nurses of the three wards were sent to participate in the international nursing new progress study class. After the study, all The nurse reported.

3. Strengthen the construction of medical ethics and medical style among nursing staff

1. Continue to implement the nurses’ behavioral norms and implement 50 sentences of nurses’ civilized language in daily work.

2. Organize all nurses to participate in etiquette training at Wenling Hotel and Wanchang Hotel in June and November respectively.

3. Continue to carry out health education, issue satisfaction survey forms to inpatients, (regular or irregular assessment) satisfaction survey results are above 95%, and raise issues existing in the satisfaction survey Corrective measures were taken and the best nurses were selected.

4. The department holds regular work break symposiums once a month to solicit the opinions of patients and provide maximum satisfaction to the patients' requirements.

5. Conduct pre-job professional ethics education, rules and regulations, nurse behavioral standards education, and basic nursing knowledge, specialist knowledge, and nursing technology operation assessments for newly assigned nurses. Those who pass the job will be given the job.

4. Improve the professional quality of nursing staff

1. Conduct three-level training for in-service personnel and organize theoretical examinations.

2. Cooperate with the medical department and hire experts to teach orthopedics, internal medicine and surgery to improve professional knowledge.

3. Each department will ask questions 1-2 times a week in the morning, covering basic theoretical knowledge and orthopedic knowledge.

4. A nursing technology operation competition (sterile operation) was held on "Women's Day", and the first prize (Wu Weiwei), the second prize (Li Mindan, Tang Haiping), and the third prize were selected (Zhou Lijun) gave rewards respectively.

In May and early December, the Nursing Department conducted a nursing technical operation assessment for all nurses in the hospital:

Ward nurse assessment: intravenous infusion, oxygen inhalation; emergency room nurse assessment: cardiopulmonary Resuscitation, oxygen inhalation, gastric lavage; operating room nurse assessment: intravenous infusion, aseptic operation.

6. Strengthened the care of critically ill patients and adhered to the bedside handover system and morning care.

7. Adhere to the nursing business rounds: Carry out nursing business rounds in three wards every month, and discuss nursing diagnosis and nursing measures to achieve the purpose of improving professional quality.

8. From September to November, pre-job training was conducted for 9 new nurses who entered the hospital this year. The content was basic nursing and specialist nursing knowledge. The head nurse was organized to give a class for each head nurse to improve their skills. Teaching ability.

9. There are 5 nurses in the hospital taking the self-study examination for nursing college, and 3 nurses taking the nursing college correspondence course.

5. Strengthened the management of nosocomial infections

1. Strictly implemented the policies formulated by the hospital management leading group...>>

Question 5: How to formulate a care plan for critically ill patients 1) Closely observe vital signs and state of consciousness, and make a detailed record.

2) Keep the respiratory tract open. Comatose patients turn their heads to one side and often inhale respiratory secretions.

3) Strengthen daily care and prevent complications.

① Pay attention to nutrition; ② Take good oral care and keep the mouth clean; ③ Take good skin care to prevent bedsores; ④ Patients whose eyelids cannot be closed should be covered with erythromycin ointment or Vaseline gauze to protect the cornea; ⑤ Keep defecation and defecation unobstructed. If an abnormality is found, handle it promptly.

4) Pay attention to safety and use protective equipment for patients with loss of consciousness, delirium, and agitation to prevent falls.

Question 6: Core content of nursing plan 1. Personnel planning

2. Personnel selection

3. Personnel development

4. Training and education

Question 7: How to write a care plan for chest tightness? Pelvic inflammatory disease refers to inflammation of the female upper reproductive tract and its surrounding tissues, mainly including endometritis, fallopian tubes, fallopian tube ovarian abscess, and pelvic peritonitis. The treatment of pelvic inflammatory disease can be treated with a combination of traditional Chinese and Western medicine, and heat-clearing and detoxifying methods are selected according to the patient's symptoms. , the treatment of promoting blood circulation and removing blood stasis is combined with high-efficiency drugs of Western medicine. The treatment must be persisted, and the medication cannot be stopped until the symptoms disappear. This may easily cause recurrence or even lead to the occurrence of 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 process of clinical application of nursing procedures, relevant patient health information, nursing diagnosis, nursing goals, nursing measures, nursing records and effect evaluation, etc. There should be written records that constitute the nursing medical record. Nursing plan: Based on nursing diagnosis, it is a dynamic decision-making process that designs how to meet the patient's needs, increase the patient's comfort, maintain and promote the patient's function, and promote the patient's recovery.