Steps
Step 1
Internal Medicine Case Selection and Systematic Nursing Assessment Design
The core task of this step is to select a typical internal medicine disease case and design a systematic nursing assessment plan. Internal medicine diseases have long courses, multiple complications, and complex nursing problems.
• Select typical internal medicine case: choose from respiratory (COPD, pneumonia, asthma, respiratory failure), cardiovascular (hypertension, CAD, heart failure, arrhythmia), digestive (cirrhosis, peptic ulcer, pancreatitis), endocrine (diabetes, hyperthyroidism); obtain complete history, physical exam, and diagnostic test data
• Design systematic nursing assessment plan: design assessment content by body system (respiratory, cardiovascular, digestive, urinary, neurological, endocrine, hematologic, skin/musculoskeletal); add specialty assessment items (NYHA classification, respiratory function, nutritional assessment, pain assessment); establish assessment process and timeline
• Prepare assessment tools and supplies: stethoscope, sphygmomanometer, thermometer, pulse oximeter, glucometer, weight scale, measuring tape, penlight, reflex hammer; prepare relevant scales (mMRC dyspnea scale, NYHA functional class, Berg balance scale, Braden scale)
Deliverable: Case summary, systematic nursing assessment plan, assessment tool list, specialty assessment key points table | Quality standard: Typical and appropriately complex case, systematic and comprehensive assessment plan, prominent specialty features, fully prepared tools
Step 2
Systematic Nursing Assessment and Specialty Physical Examination
The core task of this step is to conduct comprehensive and systematic nursing assessment, focusing on disease-related specialty physical examination. Internal medicine nursing assessment requires mastery of each system's examination skills and accurate identification of abnormal signs.
• Health history collection and general assessment: collect present illness (onset, triggers, main symptoms, treatment course), past history, medication history, allergies, family history, psychosocial history through interview; measure vital signs (T, P, R, BP, SpO2); assess consciousness and general condition
• Systematic physical assessment: conduct head-to-toe examination by systems: respiratory (inspect chest, palpate fremitus, percuss resonance, auscultate breath sounds and rales), cardiovascular (inspect apical impulse, palpate thrills, percuss cardiac borders, auscultate heart sounds/murmurs), digestive (inspect abdominal contour, palpate tenderness/rebound tenderness, percuss shifting dullness, auscultate bowel sounds); document all positive signs in detail
• Specialty focused assessment: conduct in-depth specialty assessment for the primary disease: e.g., for respiratory disease, interpret ABG, analyze pulmonary function, assess sputum clearance ability; for cardiovascular disease, assess NYHA functional class, edema degree, 24-hour intake/output, cardiac monitoring
Deliverable: Complete nursing assessment form, systematic physical examination record, specialty assessment report, abnormal sign summary, laboratory/imaging result analysis | Quality standard: Complete and accurate assessment data, standardized and skillful examination, comprehensive abnormal sign identification, in-depth specialty assessment
Step 3
Nursing Diagnosis Establishment and Internal Medicine Care Planning
The core task of this step is to analyze assessment data, establish nursing diagnoses, and develop a comprehensive internal medicine care plan. Internal medicine patients usually have multiple nursing diagnoses requiring prioritization based on severity.
• Establish and prioritize nursing diagnoses: systematically analyze assessment data; using NANDA-I classification, list at least 6 nursing diagnoses; each includes name, definition, defining characteristics (subjective + objective), related factors; prioritize by high (impaired gas exchange, excess fluid volume), medium (activity intolerance, imbalanced nutrition), low priority; explain prioritization rationale
• Develop nursing goals and interventions: set expected goals (short-term + long-term, SMART) and specific interventions for each diagnosis; focus on: condition observation (symptom/sign monitoring, lab monitoring, complication observation), symptom management (dyspnea care, pain management, fever care, edema care), treatment collaboration (medication administration, oxygen therapy, special treatment care)
• Specialty care plan: develop specialty-specific care plan for the primary disease: e.g., airway management and mechanical ventilation care for respiratory failure, volume management and activity plan for heart failure, glucose monitoring and diet/exercise guidance for diabetes, dietary management and complication prevention for cirrhosis
Deliverable: Nursing diagnosis list (with prioritization rationale), internal medicine care plan (goals, interventions, rationale, evaluation time), specialty clinical pathway table | Quality standard: Accurate and standardized nursing diagnoses with reasonable prioritization, targeted care plan with specific, evidence-based interventions
Step 4
Nursing Intervention Implementation and Dynamic Condition Monitoring
The core task of this step is to implement nursing interventions according to the care plan and dynamically monitor condition changes, adjusting the care plan promptly. Internal medicine conditions are complex and changeable, requiring keen observation and critical thinking.
• Implement nursing interventions: carry out nursing care according to plan including basic care (oral care, skin care, elimination care, dietary care), treatment care (medication administration methods, efficacy observation, adverse reaction monitoring, oxygen therapy, nebulization, drainage care), specialty care (breathing exercises, cardiac rehabilitation, insulin injection, glucose monitoring)
• Dynamic condition monitoring: develop condition observation checklist; monitor vital signs, consciousness, main symptom changes, lab results, intake/output each shift; focus on early signs of complications (worsening dyspnea, chest pain, hematemesis/melena, altered mental status, abnormal glucose); promptly report to physician and assist with management
• Nursing documentation and outcome evaluation: use PIO or SBAR format for dynamic nursing records; evaluate nursing outcomes each shift; compare actual condition with expected goals; analyze goal achievement; revise care plan promptly; record adjustment rationale and process; demonstrate continuity and dynamism of nursing
Deliverable: Nursing implementation records, dynamic condition monitoring records, complication observation and management records, revised care plan, nursing outcome evaluation form | Quality standard: Nursing interventions fully implemented, timely and perceptive condition monitoring, accurate abnormal finding management, standardized and complete documentation
Step 5
Health Education and Internal Medicine Nursing Case Report Writing
The core task of this step is to develop an individualized health education plan for the patient and write a complete internal medicine nursing case report. Health education is a critical component of internal medicine nursing, essential for chronic disease self-management.
• Develop health education plan: assess learning needs, learning ability, and health beliefs of patient and family; develop systematic education plan covering: disease knowledge (etiology, manifestations, treatment principles), medication guidance (drug names, effects, dosage, administration, side effects, precautions), dietary guidance, exercise guidance, self-monitoring methods, complication prevention, when to seek care, psychological adjustment
• Implement health education and evaluate effectiveness: use various teaching methods (verbal explanation, demonstration, written materials, videos, group discussion); implement education in stages; use teach-back method to evaluate patient understanding; assess changes in patient self-management ability (correct BP/glucose measurement, correct inhaler use, correct diet adherence)
• Write internal medicine nursing case report: follow nursing case report standards including case introduction, nursing assessment, nursing diagnoses, care plan and implementation, nursing outcomes, discussion and reflections; focus on nursing difficulties, innovations, evidence basis; summarize lessons learned; demonstrate internal medicine specialty nursing characteristics and holistic care philosophy
Deliverable: Patient health education manual, health education effectiveness evaluation form, internal medicine nursing case report, nursing experience summary | Quality standard: Individualized and systematic health education with good outcomes, complete case report with in-depth analysis demonstrating specialty nursing level