(1) definition

The process of collecting data from all aspects in a step-by-step and planned way to evaluate the health status of patients is called estimation.

Evaluation is the beginning of nursing procedure, and the evaluation stage is the basis of providing high-quality individualized nursing, which provides basis for determining nursing diagnosis, setting goals, implementing nursing plan and evaluating nursing effect of each patient. Therefore, it is very important to collect data. In addition to the overall estimate at the time of first admission, it is necessary to estimate the patients during the implementation of nursing procedures, which will help to determine the patients' progress in time, find new problems during their hospitalization, and decide whether to modify, interrupt or continue nursing measures according to these data.

(b) Content and scope of data collection

Data collection should be based on people's basic needs and patient-centered, that is, the health status of patients and their response to current diseases are the most important issues that nurses should care about and solve. Therefore, nurses should focus on understanding patients' health status, growth and development, lifestyle, environment and physiological and psychological reactions to diseases. So as to make a decision on how to help patients recover their best functional state. Data can be collected from the following 14 aspects:

1. Social and psychological state

(1) Social status includes the patient's occupation, unit, position, economy, education level, religious belief and people who have an influence on the patient's life.

(2) Family status, family members, patients' role in the family, living conditions, etc.

2. Mental and emotional state

(1) Perception ability allows patients to tell where they are, what day it is today, identify people, and check their writing and speaking skills and vocabulary level.

(2) The patient's response to stress.

(3) the reaction to people, things and things around you, whether you have been hospitalized before, whether you are afraid of being hospitalized this time, etc.

(4) What are the patients' requirements for nursing?

(5) Patients' views on their present situation, self-image concept and expected health status.

3. Reproductive system

Changes in asexual function. Women should know about menstrual history, childbirth and family planning.

4. Environmental conditions

(1) sense of security.

(2) From the analysis of patients' age or mental condition, whether safety protection measures, such as bed bars, are needed.

(3) Whether there are environmental factors causing cross infection.

Feel the situation

(1) Vision, light reflection, hallucination, hallucination, etc.

(2) Whether the hearing can clearly hear the general sound, whether there is a problem with hearing in one ear or both ears, and whether there is tinnitus.

(3) Check whether the sense of smell of patients is different.

(4) Whether the taste has the simplest and most basic taste and whether it is different.

(5) Touch includes all kinds of pain, cold and heat, and tactile feelings.

6. Active nervous state

(1) activity state, whether the action is limited and the endurance of daily activities and strenuous activities.

(2) Musculoskeletal status, joint mobility, grip strength, walking style, whether crutches and other tools are used, and whether the muscles of limbs are atrophied and flaccid.

7. Nutritional status

(1) How much do you eat a day, what do you like to eat, whether you often feel full or hungry, whether you have picky eating habits, etc.

(2) Whether the height, weight and mobility are too thin or obese, whether there is weight loss and its degree, and understand the nutritional status by observing the skin and nails.

(3) Whether appetite has changed recently, and what factors affect appetite.

(4) Whether the digestive system has false teeth, missing teeth, dysphagia, nausea and vomiting, whether the gastrointestinal tract has a history of surgery, and whether digestion and appetite are affected by special examination, treatment or medication.

8. Excretion state

(1) Whether the patient's excretion habits have changed at present.

(2) Which methods are helpful for patients to excrete normally.

(3) Causes of excretion changes.

(4) Whether the way of excretion is changed and whether auxiliary facilities are needed.

(5) Are there any other special problems recently, such as urinary incontinence, constipation, diarrhea, urinary retention, urinary incontinence, frequent urination, nocturia, etc.

9. Balance of water and electrolyte

(1) Normal intake and excretion, such as daily food intake, liquid intake and urine output.

(2) Whether there are any special health problems that affect normal intake, whether there is excessive drinking, what is the reason, and whether there are signs of edema and dehydration.

(3) Check the blood pH value to understand the electrolyte situation, and measure the blood pressure to understand the circulating blood volume.

10. Periodic status

(1) Pulse rate, intensity, rhythm and pulse type.

(2) Whether the heart sounds are normal and whether the heart rate and pulse rate are consistent.

(3) Whether the blood pressure is normal or not, the upright blood pressure, supine blood pressure and blood pressure of both upper limbs should be tested respectively.

(4) Observe the skin, lips and nails to understand the surrounding circulation.

(5) Data reports and images of cardiac monitoring.

(6) Laboratory examination and its clinical significance.

1 1. Respiratory state

(1) directly observe whether the respiratory tract is unobstructed, and the effects of breathing frequency, breathing sound and body position on breathing.

(2) indirectly observe whether there is a smoking history, daily smoking volume and cigarette types; Whether there are smokers around; Whether to take drugs that affect the function of respiratory system; Whether anxiety and fear affect breathing; Whether to use ventilator and oxygen to assist breathing; Color and type of skin, lips and nails; Laboratory examination results and its clinical significance.

12. Body temperature status

(1) The patient complained of his body temperature.

(2) Do patients (family members) know the general measures to cool down when they have a fever and keep warm when they have chills?

(3) Measure the body temperature and know the basal body temperature.

(4) The time and manner of sweating and the existence of night sweats.

13. Skin condition

(1) Skin color, elasticity, dryness and wetness, integrity, subcutaneous hemorrhage, bedsore and other injuries.

(2) Hygienic habits and skin excretion.

65438+

(1) causes of discomfort, and what measures can be taken to make patients feel uncomfortable.

(2) Whether sleep is sufficient, what methods are used to help sleep, whether diseases affect sleep or other reasons, and whether you feel sleepy and tired during the day.

Nurses know the patient's information from the above 14 aspects to see if the patient can satisfy it. If they find that a basic need is not met, they can find the reason.

(3) Data type

The types of data include subjective and objective data, past and present data, fixed and variable data.

1. Subjective and objective data Subjective data is the patient's chief complaint, including his feelings, attitudes, wishes and needs for the disease. Such as nausea, dizziness, pain, etc. Are subjective data. Objective data is the observation of medical staff. Determine by observation, measurement, physical examination or laboratory examination. For example, the patient's height, weight and blood pressure are all objective data. The information of subject and object can provide information for patients' health and help identify problems.

2. Past and present data Past data is what happened in the past. Including past history, hospitalization history, family history, habits that affect health, etc. The current data is what exists at present. Such as blood pressure, vomiting and postoperative pain. The present and past data can get the concept of time when estimating or can be compared with the usual behavior habits. And the two can be combined to confirm the problem or identify the contradiction.

3. Fixed and variable data Some data are fixed, such as date, place and patient's gender. Some data are variable, such as the patient's weight, temperature, blood pressure, food intake and output. Pay attention to the dynamic observation of variable data, collect records regularly, and make analysis and judgment.

Methods of collecting data

1. Methods There are four main methods to collect data, namely reading, talking, observing and measuring.

(1) Reading includes consulting medical records, relevant records and documents, and knowing the patient's name, occupation, chief complaint, examination results, preliminary diagnosis, medical measures, etc. Only in this way can the conversation be targeted and take the initiative.

(2) Conversation includes asking and listening to patients. The main purpose of talking with patients in nursing evaluation is to collect information such as patients' past health status, current reaction to diseases, family and social situation, obtain all kinds of information needed to establish nursing diagnosis, and also establish a good nurse-patient relationship. While talking about nursing evaluation, patients can also get information about their own diseases, treatment and nursing, make suggestions and provide spiritual and psychological support.

Nursing evaluation talks should be held not only when patients are admitted to hospital, but also in the later nursing process to evaluate the progress of the disease or give education, guidance and help. Therefore, nurses should master the basic knowledge, methods and skills of communication, so as to get in touch with patients more easily and get real and timely information, and then input the program and apply it to nursing work.

(2) Observation is the basic method of scientific work and the skill that nurses should master in any nursing activities. Systematic observation includes comprehensive understanding of patients' physiological and psychological state by using senses such as vision, touch, hearing and smell. Verifying and supplementing the information collected in the conversation through relevant observation is conducive to making scientific judgments on nursing problems (Table 23- 1).

Table 23- 1 main contents of nursing observation

The patient's appearance and functional characteristics, the content and process environment of patient's interaction and conversation with others.

Vision, eye posture, gait balance, dress modification, complexion, lip color, tongue coating, mucous membrane, hair, nail shape, prosthesis secretion, excreta characteristics, body movements, gestures, eyes, expressions, patients' reaction to their families, family members' attitude towards patients, cleanliness of wards and sickbeds, cleanliness of clothes and appliances, influence of light on patients, convenience and comfort of daily life, etc.

Touch skin temperature, humidity, elastic tension, muscle strength, pulse change, lump size, tenderness, air humidity, cleanliness and item quality.

Auditory language ability, heart sounds, lung sounds, intestinal sounds, auscultation, percussion, cough, blood pressure changes, the intensity of voice when talking with others, and the special content of the story. Are there any factors that stimulate hearing in ward noise?

Special smells of taste, smell, phlegm, urine, feces and vomit.

Nursing observation should be carried out in a certain order, and there are two common observation methods; First, from head to toe, that is, in the order of head, neck, chest, abdomen, spine, limbs, genitals, anus, nerve reflex, communication and environment, to avoid unnecessary repetition and omission. Second, according to several major systems, that is, starting from several major systems of the body, rather than starting from the local. Usually, the hospital will print the key inspection items on the physical examination form according to the system, so that there is no omission or repeated inspection. When observing, we should comprehensively use the senses such as vision, touch, hearing and smell.

(4) Measurement is to use some instruments to supplement and confirm the information obtained from sensory observation, so as to measure the height, size, frequency, rhythm and quantity of things. The measured data include laboratory results, vital signs, height, weight and urine volume. Some quantitative general observation data can also be used as measurement data, such as the number of cigarettes smoked during conversation, the amount of three meals a day, ECG monitoring observation data and so on.

2. The following questions should be paid attention to when carrying out nursing evaluation.

(1) Establish a good nurse-patient relationship. A good nurse-patient relationship is conducive to collecting information, especially information related to patients' emotions and understanding, and to understanding each other's language.

(2) When collecting data, it is generally necessary to estimate the main health problems of patients and various situations related to these problems first, and then collect the general health status of patients.

(3) Data sources can be varied. Patients are often the main source of data, but don't ignore other data sources, such as patients' families, relevant personnel in work units, doctors, medical records, etc.

(4) When collecting data, the appropriate method should be selected, and the most appropriate method should be determined according to the patient's age, health status and data source. For some useful information, there must be at least two ways to collect information.

(5) The data must be objective. The data collected through conversation, observation and measurement must be objective. Nurses' interpretation of these data can be used as the basis for further data collection, but it must not be the data itself.

(6) The work of collecting data is continuous. After the first nursing evaluation, the collected data will be integrated and analyzed. At this time, some gaps are often found, that is, omissions that have not been collected. In order to make the nursing diagnosis correct, it is necessary to go back to the patient and supplement the collected data. In the follow-up nursing process, new information will appear constantly, so it is necessary to predict it in time.

Second, the nursing diagnosis

(1) definition

Nursing diagnosis is a description of the existing or potential physical and mental health problems of patients, which belongs to the scope of nursing work, and nurses have the responsibility and ability to deal with them. Specifically, nursing diagnosis means that nurses ask, examine and examine patients, and through understanding the patients' condition, psychology, family and social conditions, judge the core problems that need to be solved in nursing methods, and make conclusions accordingly.

(2) Composition and formula of nursing diagnosis

1. To establish the composition of nursing diagnosis, there should be four basic connotations.

(1) Diagnostic name is an overview description of the health status of the nursing object, that is, diagnostic name, also known as general health topic.

(2) Definition Definition is a clear expression of diagnosis name to distinguish it from other diagnoses. For example, the change of oral mucosa is defined as the destruction of oral mucosal tissue.

(3) Relevant factors of diagnosis refer to all kinds of direct and main contributing factors and risk factors that can cause problems or affect the development of problems.

(4) The basis of diagnosis includes physical, psychological and social manifestations.

2. Formula nursing diagnosis includes three parts, called pes formula.

(1) Health problem is the name of nursing diagnosis, and it is a description of the existing or potential situation of individual health. These problems all reflect the change of health status, but they can't explain the degree of change.

(2) Etiology, that is, related health problems or related factors or risk factors. The reason often refers to the direct factor that causes the problem. Related factors often refer to the related factors that cause problems.

(3) Signs and symptoms, a group of symptoms and signs observed in patients, are often important features of health problems.

For example, malnutrition P and obesity S are related to excessive dietary intake. E. Clinical nursing diagnosis is often the problem (or symptoms and signs)+cause (in definite cases, or related factors, such as pe or se formula, such as "postoperative wound causes pain" and "anxiety is related to worrying about unsatisfactory surgical results".

(3) Types of nursing diagnosis

Nursing diagnosis can be divided into two types, and determining the type of nursing diagnosis mainly depends on symptoms and signs.

1. The diagnosis of existing symptoms refers to the problems that the patient is experiencing at the moment, that is, the symptoms that the patient has shown, such as "the change of the original comfortable state is related to the forced lying position of thigh traction", and the patient is accompanied by a series of symptoms or signs such as pain, general discomfort, poor sleep and limited activity.

2. The diagnosis of potential symptoms means that the patient does not have some specific symptoms and signs at present, but has some precursors or some risk factors. If risk factors are not considered and preventive measures are not taken in nursing, patients will have problems. For example, "potential falls are related to muscle weakness", and the diagnosis of these potential problems that affect health is called the diagnosis of potential symptoms. Another type is "possible nursing diagnosis", which means that when there is not enough information to support the existing or potential nursing diagnosis, "possible nursing diagnosis" can be written. At this time, nurses should continue to collect information about this problem, and rule out this diagnosis or make a further diagnosis according to supplementary information.

(D) Differences and connections between nursing diagnosis and medical diagnosis

Therapeutic diagnosis is a description of a disease and a group of symptoms and signs, with a name to explain the cause and pathophysiological changes of the disease, so as to guide the treatment measures; Nursing diagnosis describes the existing or potential nursing problems that affect patients' health due to pathological and psychological changes, and is the basis for formulating nursing measures. Nursing diagnosis is made by nurses. Nursing diagnosis should refer to medical diagnosis, understand patients' pain and physiological needs, take measures to cooperate with medical treatment or doctors to treat diseases, and promote and restore patients' health. It is also necessary to establish different nursing diagnoses according to the individual differences of patients, different psychological and social factors, and different characteristics of their reactions and needs to diseases. The same disease can have different nursing diagnosis, and different diseases can also have similar nursing diagnosis. It is generally believed that nursing diagnosis involves three aspects.

1. Cooperative nursing diagnosis If the doctor's advice is carried out, in this category, the nurse's duty is to make the treatment plan in the doctor's advice accurately implemented. Generally, it is not necessary for nurses to diagnose the problems within the scope of doctor's advice, but it is necessary for nurses to make nursing diagnosis in the process of implementing doctor's advice. For example, if diabetic patients are found to have premonitory symptoms of hypoglycemia, nurses should diagnose "hypoglycemia may be related to the use of insulin", accurately detect urine sugar, adjust diet according to standards, strictly record food intake, observe clinical symptoms, and provide doctors with the basis for adjusting insulin dosage.

2. The goal of collaborative nursing diagnosis for patients is often achieved through the cooperation between nurses and doctors. For example, patients with cerebrospinal fluid leakage "have the possibility of intracranial infection", the medical field is to choose antibiotics, and the nursing work is to cut off the source of infection. For example, put the patient in a clean ward, keep a proper lying position, put a sterile treatment towel on his head, and clean the nasal cavity and external auditory canal regularly to prevent retrograde infection or scab. Prevent colds and prevent coughing from affecting crack healing. This is a process in which doctors and nurses cooperate for the same goal-preventing intracranial infection.

3. Independent nursing diagnosis According to the patient's existing or potential physical and mental pain or adverse reactions, within the scope of nursing functions, nurses have the responsibility to diagnose the patient's health problems and choose their own nursing measures to promote health or alleviate diseases. Limit and prevent all kinds of negative factors that are not conducive to health, including life care, functional exercise, nutritional metabolism, excretory function, rest and sleep, cognitive perception, emotional behavior, family and social support, etc. For example, when patients are afraid of coughing or unable to cough up secretions due to pain, the nursing diagnosis is that "respiratory secretions cannot be effectively removed, which is related to sticky sputum and inability to cough up". Nursing measures are turning over regularly, knocking on the back, atomizing inhalation and blowing bubbles to exercise patients, helping to maintain correct posture, effectively guiding abdominal breathing and coughing to promote sputum discharge and preventing pulmonary complications.

Independent nursing diagnosis is the work done by nurses independently, which is essentially different from medical diagnosis. Cooperation and cooperative nursing diagnosis are related to medical diagnosis. After the patient's medical diagnosis is established, corresponding cooperation and collaborative nursing diagnosis are often adopted, but this is not absolute. Due to the differences of patients' physiological, psychological, family and social factors, the nursing diagnosis of the same medical diagnosis may be different.

The establishment of nursing diagnosis is the embodiment of nurses' independent responsibilities, which is helpful for nurses to decide nursing goals and measures for patients. The role of nursing diagnosis is that nurses can put forward preventive measures, such as health education, function, bedsore prevention and complications prevention. Corrective measures can also be put forward, such as squeezing chest tube regularly to help patients cough, so as to solve the possibility of reducing the efficiency of closed thoracic drainage tube.

In a word, nursing diagnosis reflects the patient's physiological, psychological and social conditions, and suggests the care that patients should receive, which is essentially different from medical diagnosis and closely related.

(5) Problems that should be paid attention to when writing nursing diagnosis.

1. This question is clear and easy to understand.

2. Diagnosis is aimed at a specific set of problems.

3. Nursing diagnosis must be based on the collected data. Different patients with the same disease may not have the same nursing diagnosis. It depends on the patient's data, and there should be enough evidence to make a diagnosis.

4. The identified problems need to be solved, alleviated or monitored through nursing measures, rather than problems related to the medical field.

5. Nursing diagnosis should provide direction for nursing measures, so the statement of reasons or related factors must be detailed, specific and easy to understand. For example, "Sleep disorder is related to hospitalization", and this diagnosis does not provide direction for nursing measures. It is better to state as follows: "Sleep disorder is related to hospitalization destroying family life habits" to provide some information for nursing.

Third, the nursing plan

(1) Definition: To formulate specific nursing measures for nursing diagnosis. Planning is the guidance of patients' nursing activities, and it is to find some measures for nursing diagnosis to prevent, alleviate or solve related problems. The purpose of making the plan is to make the patient get the care suitable for him, maintain the continuity of nursing work, promote the communication between medical staff and facilitate the evaluation.

(II) Contents In the planning process, we should set goals and formulate measures.

1. Setting goals is an ideal nursing result. Its purpose is to guide the formulation of nursing measures and measure the effectiveness and practicability of the measures. To this end, the target should have the following characteristics; We must take the patient as the center and reflect the patient's behavior; Must be realistic and feasible; Observable and measurable, with specific detection standards; There is a time limit; Formulated jointly by nurses and patients.

There are long-term goals and short-term goals, which take a long time to achieve and have a wide range; Short-term goals are the steps to achieve long-term goals or the main contradictions to be solved. For example, the long-term goal of patients with lower limb fractures is to restore their walking function within three months, and the short-term goal is to walk with crutches in the first month, walk with crutches in the second month, and gradually walk independently in the third month. Short-term goals and long-term goals complement each other and echo each other.

2. Formulating nursing measures Nursing measures is to explain the behavior of helping patients achieve the expected goals, and it is a specific nursing work item put forward by nurses for patients; It is a concrete implementation plan after establishing nursing diagnosis and goals. Focus on health; Maintain normal function; Prevent loss of function; Meet people's basic needs; Prevent, reduce or limit adverse reactions.

Nursing measures can be divided into three categories: dependence, interdependence and independence:

(1) Dependent nursing measures are specific methods for nurses to carry out doctor's orders, and describe the behavior of carrying out medical measures. Such as the doctor's advice "weigh 3 times a week". Nurses perform the following tasks: Weigh before breakfast every Monday, Wednesday and Friday.

(2) Interdependent nursing measures This kind of nursing measures includes the cooperation among doctors, nurses, technical nutritionists and physiotherapists. By the nurse contact doctor's advice, * * * with execution. For patients with renal failure, the doctor's order is "oral liquid 50 ml every 24 hours" and intravenous infusion of 5% glucose 700 ml. When carrying out the above-mentioned doctor's orders, the nurse should work with the nutritionist to calculate the amount of liquid that the patient must take in each shift. The measures formulated by nurses are as follows:

① Intravenous rehydration 30ml// hour, controlled by infusion pump.

② Oral liquid:

From 7:30 a.m. to 3:30 p.m., the total amount is 3 15ml, including 240ml food intake and 75ml medicine intake.

3: 30pm-11:30pm, the total amount is 195ml, and 120ml is taken from food when taking 75ml medicine.

165438+ 0: 30 pm-7:30 am, the total amount is 100ml.

(3) Independent nursing measures This kind of nursing measures are completely designed and implemented by nurses and do not need doctor's advice. Nurses rely on their own knowledge, experience and ability to make according to nursing diagnosis; It is the scale of independent thinking, judgment and decision-making within the scope of duties.

Example: A 52-year-old female patient with duodenal ulcer complained of insomnia. After analyzing the collected data, it is considered that insomnia is related to daytime sleep. Nurses make the following measures according to the patient's situation and their own experience: ① patients should not fall asleep from 7 am to 9 pm; ② Take a walk every day when you want to sleep; (3) Before going to bed, help patients to carry out activities to promote sleep, wash feet with warm water, read newspapers, listen to light music and relax therapy.

Nursing measures should have the following characteristics and components: making full use of various suitable resources, including equipment, economic strength and human resources; Accord with reality and embody individualized nursing; The content is concrete, clear and concise; Patients are involved; There is a scientific theoretical basis. In order to ensure the correct implementation, nursing measures should include: date, verb, who will implement it? What time? What should I do? How? Where is it? Some routine operation steps do not need to be written in the Measures. If the patient can't follow the routine procedures due to special circumstances, it should be listed in the nursing measures. The final content of nursing measures is signature.

Nursing guidance is an integral part of nursing plan. The contents of nursing guidance include: nursing grade, diet nursing, condition observation, basic nursing, nursing before and after examination, psychological nursing, maintenance of management efficiency, functional exercise, health education, symptomatic nursing and doctor's advice execution. The nursing instructions should be clear and specific, specially put forward to meet the nursing needs of a patient, and should not be the same as the routine.

Fourth, the implementation plan

(1) defines implementation as the process of putting all the planned measures into action in order to achieve nursing goals. Including all kinds of nursing activities to solve nursing problems, recording the results of nursing activities and patients' reactions.

The implementation is designated by the planner or others, and patients actively participate. The key point of the implementation process is to make nursing behavior personalized and safe. The quality of implementation is related to nurses' knowledge level, interpersonal skills and operational skills. The situation in the implementation process should be recorded in words at any time.

(2) Preparation before implementation

1. Further understand and understand that the executor of the plan should be familiar with the purpose, requirements, methods and time arrangement of the measures in the plan to ensure the implementation of the measures and make the nursing behavior consistent with the plan. In addition, nurses should also understand the theoretical basis of various measures to ensure scientific nursing. The way to be familiar with the plan is to read relevant books on the basis of reading the plan, or organize discussions in the ward and the responsibility team to analyze the plan of key patients.

2. Analysis of required nursing knowledge and skills Nurses must analyze the nursing knowledge and skills needed to implement these measures. If it is insufficient, you should consult relevant books or materials or consult other relevant personnel.

3. Clear the possible complications and prevent the implementation of some nursing measures in time, which may cause certain harm to patients. Nurses must fully foresee possible complications, avoid or reduce the harm to patients and ensure the safety of patients.

4. Reasonable arrangement, scientific use of time, manpower and material resources to implement nursing measures should be reasonably selected and arranged, and your own time should be estimated to ensure that you have enough time to complete the implementation of this measure to prevent improper implementation due to haste. In the arrangement of manpower, the head nurse or head nurse should also ensure that there are enough and suitable personnel to complete the corresponding work. In addition, we should also consider preparing necessary equipment to create an environment that makes patients feel comfortable, safe and conducive to nurses' work.

(3) Implementation process In the implementation stage, the focus of nursing is to implement the established measures, carry out the doctor's advice and nursing, so as to achieve the goal and solve the problem. In practice, we should not only pay attention to every measure according to the standard of routine nursing operation, but also pay attention to individualized nursing according to the physiological and psychological characteristics of each patient.

Health education should be carried out to meet the learning needs of patients. The content includes acquiring knowledge, learning operation technology and changing personal psychological and emotional state.

Implementation is a continuation of the assessment, diagnosis and planning stages. We should always pay attention to estimate the patients' physiological and psychological state, understand the patients' tolerance, reaction and effect of the measures, and strive to make the nursing measures meet the patients' physiological and psychological needs and promote the recovery of the disease.

The responsible nurse is the main person to carry out the plan. She must also rely on the assistant nurses in each class and get the cooperation and support from patients and their families. Nursing activities are closely related to medical work, although each has its own content, but the overall goal is the same. Therefore, medical personnel should exchange information and cooperate closely in the implementation.

In practice, the responsible nurse should make a complete and accurate written record of the results of various nursing activities and patients' reactions, that is, the nursing course record in the nursing medical records. Reflect the nursing effect and prepare for the evaluation.

Verb (abbreviation for verb) evaluation stage

(1) Definition evaluation is a planned and systematic comparison process between the patient's health status and the original nursing goal. Evaluation is an activity that runs through the whole nursing process, and the data of patients' initial evaluation stage is the basic data for comparison in evaluation; Nursing diagnosis is the basis of evaluation; Nursing goal is the standard of evaluation.

(2) The most important purpose of objective evaluation is to determine the extent to which the patient's health status has progressed to the target. At the same time, it is also a process of judging the formulation and implementation effect of nursing measures. While measuring the improvement of patients' health status, it is also a process of evaluating nursing quality and promoting the improvement of nursing work.

(3) The content evaluation system includes three aspects: organization evaluation, nursing procedure evaluation and nursing effect. The evaluation of these three aspects is very important, but the most important is the evaluation of nursing effect, which can provide strong proof for the nursing effect of nursing state; The evaluation of nursing procedure is to evaluate the correctness of nurses' behavior in each step of implementing nursing procedure, which is conducive to the best effect of nursing; Organizational management evaluation ensures the application of nursing procedures and the effectiveness of nursing. Therefore, they are interrelated, influenced and restricted.