Gay C R
J Post Anesth Nurs. 1990 Apr;5(2):85-90.
The professional practice of nursing is a comprehensive discipline involving assessment, planning, implementation, and evaluation in its approach to both daily practice and problem solving. An integral part of this process is the development of nursing diagnoses, setting of goals, and evaluation of progress towards meeting those goals. In order to further professional practice in the PACU, the PACU staff at St Francis Hospital in Greenville, SC, developed a new record that incorporates nursing diagnosis, goal setting, and evaluation along with the documentation of appropriate nursing interventions to meet stated goals. The staff believed that such a record would advance their professional practice, meet the ASPAN standards of nursing practice, and meet the Joint Commission for Accreditation of Healthcare Organizations requirements that documentation in the PACU show a nursing plan of care. The need for such a record was shown in the literature search and the record was developed, tested over a 30-day period, and implemented in September 1988. Staff response to the record has been very positive with nurses indicating that the record not only improved documentation, but also increased individual accountability for initiating nursing measures to meet stated goals.
护理专业实践是一门综合性学科，在日常实践和问题解决中涉及评估、规划、实施和评价。这个过程的一个重要组成部分是制定护理诊断、设定目标以及评估实现这些目标的进展情况。为了进一步推进麻醉后护理单元（PACU）的专业实践，南卡罗来纳州格林维尔市圣弗朗西斯医院的PACU工作人员开发了一种新记录，该记录纳入了护理诊断、目标设定和评价，以及为实现既定目标而采取的适当护理干预措施的记录。工作人员认为，这样的记录将促进他们的专业实践，符合美国麻醉后护理协会（ASPAN）的护理实践标准，并满足医疗保健组织认证联合委员会的要求，即PACU中的记录应显示护理计划。文献检索表明了对这种记录的需求，该记录被开发出来，经过30天的测试，并于1988年9月实施。工作人员对该记录的反应非常积极，护士们表示，该记录不仅改善了记录，还增加了个人对采取护理措施以实现既定目标的责任感。
