Documenttion 教育部獎勵大學(xué)教學(xué)卓越計畫

1、step 3：analyze nursing diagnoses relationships draw lines between nursing diagnoses to indicate relationships. prepared to verbally explain to your clinical faculty why you have made these links if it is not obvious. concept mapping is a holistic approach to patient care. this step focuses on the re

2、lationships between diagnoses and the labeling of nursing diagnoses .step 4：identifying goals, outcomes, and interventions write patient goals and outcomes and then list nursing interventions to attain the outcomes for each of the numbered diagnoses on your map. the nursing interventions should incl

3、ude appropriate treatments and medications and patient teaching. prepared to verbally explain the goals and rationales for nursing interventions with your clinical faculty. step 5：evaluate patients responses this step is the written evaluation of the patients physical and psychosocial responses. it

4、also involves writing your clinical impressions and inferences regarding the patients progress toward expected outcomes and the effectiveness of your interventions to bring these outcomes about.documentation documentation involves correctly identifying patient assessment data to record about a probl

5、em, determining what to record about the interventions to correct the problem, and describing the patients responses to the interventions. concept map care plans as the basis of documentation - detail in chapter 7medication administration organizing the drugs to be administered relationship of the d

6、rug to the problem interacting effects of the drug related to the total clinical picture. example: digitalis - decreased cardiac output。what is the relationship between low levels of potassium and digitalis?。assessing the patient carefully for adverse reactions to the drug.nursing standards of care

7、standards of the american nurses association general standards of care standards of the joint commission on accreditation of healthcare organizations (jcaho) specific policies and procedures standardized nursing care plans based on typical nursing diagnoses nursing standards of care-cons patient edu

8、cation standards appropriate for the patients individual needs and ability insurance agency & government care standards clinical pathway / critical pathway utilization review standards review charts. judge the necessity and appropriateness of care and efficiency with which care is delivered. managed care in hospital settings there is a direct relationship between the care standards described above and the management of care. hospital-based nurse case managers assigned to monitor and coordinate their progress through the health-care system. to make