Lancaster L E, Rice V
Crit Care Nurs Clin North Am. 1990 Jun;2(2):279-86.
The systematic nursing process is an essential prerequisite for providing effective care for patients in shock. Nurses use assessment skills to identify actual and potential collaborative problems and nursing diagnoses. Once collaborative problems and nursing diagnoses are identified, the nurse develops appropriate individualized patient outcomes and plans care to accomplish the outcomes and resolve the problems. Nursing actions from the three domains may be included in the care plan. The evaluation phase assesses the adequacy of nursing actions in accomplishing the stated goals and returns the process to the stage of assessment. Application of the nursing care planning process to the patient in shock can be somewhat difficult because of the critical nature of the illness, complex assessment data, and rapidly changing interventions. It is indeed a challenge for the critical care nurse to integrate sound principles of nursing care planning into the busy intensive care environment, but the outcome of improved patient care is worth the effort.
系统护理程序是为休克患者提供有效护理的重要前提。护士运用评估技能来识别实际的和潜在的合作性问题以及护理诊断。一旦确定了合作性问题和护理诊断，护士就会制定适当的个体化患者结局，并规划护理以实现这些结局并解决问题。护理计划可能包括来自三个领域的护理行动。评价阶段评估护理行动在实现既定目标方面的充分性，并使该程序回到评估阶段。由于病情危急、评估数据复杂以及干预措施迅速变化，将护理计划程序应用于休克患者可能会有些困难。对于重症护理护士而言，将合理的护理计划原则融入繁忙的重症监护环境确实是一项挑战，但改善患者护理的结果是值得付出努力的。
