The second stage of the nursing process includes. The main stages of the nursing process. Patient Data

Nursing Process- a systematic, well-thought-out, purposeful nurse action plan that takes into account the needs of the patient. After the implementation of the plan, it is imperative to evaluate the results.

The standard nursing process model consists of five steps:

1) nursing examination of the patient, determining the state of his health;

2) making a nursing diagnosis;

3) planning the actions of a nurse (nursing manipulations);

4) implementation (implementation) of the nursing plan;

5) assessing the quality and effectiveness of the nurse's actions.

Benefits of the Nursing Process:

1) universality of the method;

2) ensuring a systematic and individual approach to nursing care;

3) wide application of standards of professional activity;

4) ensuring the high quality of medical care, the high professionalism of the nurse, the safety and reliability of medical care;

5) in the care of the patient, in addition to medical workers, the patient himself and members of his family take part.

Patient examination

The purpose of this method is to collect information about the patient. It is obtained by subjective, objective and additional methods of examination.

A subjective examination consists in questioning the patient, his relatives, familiarizing himself with his medical documentation (extracts, certificates, outpatient medical records).

To obtain complete information when communicating with a patient, a nurse should adhere to the following principles:

1) questions should be prepared in advance, which facilitates communication between the nurse and the patient, and allows you not to miss important details;

2) it is necessary to listen carefully to the patient, treat him kindly;

3) the patient must feel the interest of the nurse in their problems, complaints, experiences;

4) short-term silent observation of the patient before the start of the survey is useful, which allows the patient to gather his thoughts, get used to the environment. The health worker at this time can form a general idea of ​​the patient's condition;

During the interview, the nurse finds out the patient's complaints, the history of the disease (when it started, with what symptoms, how the patient's condition changed as the disease developed, what medications were taken), the history of life (past illnesses, lifestyle, nutrition, bad habits, allergic or chronic diseases).

During an objective examination, the patient's appearance is assessed (facial expression, position in bed or on a chair, etc.), examination of organs and systems, functional indicators are determined (body temperature, blood pressure (BP), heart rate (HR), respiratory rate). movements (RR), height, body weight, vital capacity (VC), etc.).

The legislation of the Russian Federation prohibits abortions outside a medical institution. If the artificial termination of pregnancy is performed outside a specialized medical institution or by a person with a secondary medical education, then on the basis of Part 2 of Art. 116 of the Criminal Code of the Russian Federation who performed an abortion is held criminally liable.

Plan for an objective examination of the patient:

1) external examination (describe the general condition of the patient, appearance, facial expression, consciousness, position of the patient in bed (active, passive, forced), patient mobility, condition of the skin and mucous membranes (dryness, moisture, color), the presence of edema (general , local));

2) measure the height and body weight of the patient;

5) measure blood pressure on both arms;

6) in the presence of edema, determine daily diuresis and water balance;

7) fix the main symptoms characterizing the condition:

a) organs of the respiratory system (cough, sputum production, hemoptysis);

b) organs of the cardiovascular system (pain in the region of the heart, changes in pulse and blood pressure);

c) organs of the gastrointestinal tract (state of the oral cavity, indigestion, examination of vomit, feces);

d) organs of the urinary system (the presence of renal colic, a change in the appearance and amount of urine excreted);

8) find out the condition of the places of possible parenteral administration of drugs (elbow, buttocks);

9) determine the psychological state of the patient (adequacy, sociability, openness).

Additional methods of examination include laboratory, instrumental, radiological, endoscopic methods and ultrasound. It is mandatory to conduct such additional studies as:

1) clinical blood test;

2) blood test for syphilis;

3) blood test for glucose;

4) clinical analysis of urine;

5) analysis of feces for helminth eggs;

7) fluorography.

The final step of the first stage of the nursing process is to document the information received and obtain a patient database, which are recorded in the nursing history of the appropriate form. The medical history legally documents the independent professional activity of a nurse within her competence.

Making a nursing diagnosis

At this stage, the patient's physiological, psychological and social problems, both actual and potential, priority problems are identified and a nursing diagnosis is made.

Plan for studying the problems of the patient:

1) identify current (available) and potential problems of the patient;

2) to identify the factors that caused the emergence of actual problems or contributed to the emergence of potential problems;

3) identify the strengths of the patient, which will help to solve actual and prevent potential problems.

Since in the overwhelming majority of cases, patients have several urgent health-related problems, in order to solve them and successfully help the patient, it is necessary to find out the priority of a particular problem. The priority of the problem can be primary, secondary, or intermediate.

The primary priority is the problem that requires an emergency or first-priority solution. Intermediate priority is related to the state of health of the patient, not threatening his life, and is not a priority. Secondary priority is given to problems that are not related to a specific disease and do not affect its prognosis.

The next task is to formulate a nursing diagnosis.

The purpose of nursing diagnosis is not to diagnose the disease, but to identify the reactions of the patient's body to the disease (pain, weakness, cough, hyperthermia, etc.). Nursing diagnosis (as opposed to medical diagnosis) is constantly changing depending on the changing response of the patient's body to the disease. At the same time, the same nursing diagnosis can be made for different diseases to different patients.

Nursing process planning

Drawing up a plan of medical measures has certain goals, namely:

1) coordinate the work of the nursing team;

2) ensure the sequence of measures for patient care;

3) helps to maintain communication with other medical services and specialists;

4) helps to determine the economic costs (because it specifies the materials and equipment needed to carry out nursing activities);

5) legally documents the quality of nursing care;

6) helps to subsequently evaluate the results of the activities carried out.

The goals of nursing activities are the prevention of relapses, complications of the disease, disease prevention, rehabilitation, social adaptation of the patient, etc.

This phase of the nursing process consists of four stages:

1) identifying priorities, determining the procedure for solving the patient's problems;

2) development of expected results. The result is the effect that the nurse and the patient want to achieve in joint activities. The expected results are a consequence of the following tasks of nursing care:

a) solving the patient's health problems;

b) reducing the severity of problems that cannot be eliminated;

c) preventing the development of potential problems;

d) optimizing the patient's ability in terms of self-help or help from relatives and close people;

3) development of nursing activities. It specifies how the nurse will help the patient achieve the expected results. Of all the possible activities, those that will help achieve the goal are selected. If there are several types of effective methods, the patient is asked to make his own choice. For each of them, the place, time and method of implementation must be determined;

4) including the plan in the documentation and discussing it with other members of the nursing team. Each nursing action plan must be dated and signed by the person who prepared the document.

An important component of nursing activities is the implementation of doctor's orders. Nursing interventions need to be consistent with therapeutic decisions, be based on scientific principles, be individual to the individual patient, take advantage of the patient's education and allow him to take an active part.

Based on Art. 39 Fundamentals of legislation on the protection of the health of citizens, medical workers must provide first aid to all those in need of it in medical institutions and at home, on the street and in public places.

Carrying out the nursing plan

Depending on the participation of the doctor, nursing activities are divided into:

1) independent activities - actions of a nurse on her own initiative without instructions from a doctor (training the patient in self-examination skills, family members in the rules of patient care);

2) dependent measures that are performed on the basis of the written orders of the doctor and under his supervision (performing injections, preparing the patient for various diagnostic examinations). According to modern ideas, a nurse should not automatically follow a doctor's prescription, she should think through her actions, and if necessary (in case of disagreement with a medical prescription), consult a doctor and draw his attention to the inappropriateness of a dubious appointment;

3) interdependent activities involving the joint actions of a nurse, a doctor and other specialists.

Patient care may include:

1) temporary, designed for a short time, which occurs when the patient is unable to self-care, self-care, for example, after operations, injuries;

2) constant, necessary throughout the life of the patient (with severe injuries, paralysis, amputation of limbs);

3) rehabilitating. This is a combination of physical therapy, therapeutic massage and breathing exercises.

The implementation of the nursing action plan is carried out in three stages, including:

1) preparation (revision) of nursing activities established during the planning phase; analysis of nursing knowledge, skills, determination of possible complications that may arise during the performance of nursing manipulations; providing the necessary resources; preparation of equipment - stage I;

2) implementation of activities - stage II;

3) filling out the documentation (complete and accurate entry of the performed actions in the appropriate form) - stage III.

Evaluation of results

The purpose of this stage is to assess the quality of the assistance provided, its effectiveness, the results obtained, and summarizing the results. The assessment of the quality and effectiveness of nursing care is made by the patient, his relatives, the nurse herself who performed the nursing activities, and the management (senior and chief nurses). The result of this stage is the identification of positive and negative aspects in the professional activities of a nurse, revision and correction of the action plan.

Nursing medical history

All activities of the nurse in relation to the patient are recorded in the nursing history. At present, this document is not yet used in all medical institutions, but as nursing is being reformed in Russia, it is becoming increasingly used.

The nursing history includes the following:

1. Patient data:

1) date and time of hospitalization;

2) department, ward;

4) age, date of birth;

7) place of work;

8) profession;

9) marital status;

10) who sent;

11) medical diagnosis;

12) the presence of allergic reactions.

2. Nursing examination:

1) more subjective examination:

a) complaints;

b) medical history;

c) life history;

2) objective examination;

3) data from additional research methods.

Diagnosis is designed to establish the problems that arise in the patient; factors that contribute to or cause these problems, and the strengths of the patient that would contribute to the prevention or resolution of problems.

Explicit (real) or potential (which may arise) problems of a person are entered into the nursing care plan in the form of clear and concise calculations-judgments. In the literature, these judgments are called sister diagnostic. The concept of nursing diagnosis is still new, but as knowledge in nursing

cases is growing and the potential for developing nursing diagnosis. Therefore, it is not so important what to call the second stage of the nursing process - identifying patient problemsTrinian diagnosis, diagnosing.

Often the patient himself is aware of his actual problems, for example, pain, difficulty breathing, poor appetite. In addition, the patient may have problems that the nurse is not aware of. The nurse can also identify problems that the subject himself does not know about, such as a rapid pulse or signs of infection.

The nurse must know the sources of the patient's possible problems. They are:

The environment and harmful factors affecting humans,

The patient's medical diagnosis or physician's diagnosis.

A medical diagnosis determines the disease based on a special assessment of physical signs, medical history, diagnostic tests. The task of medical diagnosis is the appointment of treatment for the patient.

3. Treating a person, which may have unwanted side effects, can be a problem in itself, eg nausea, vomiting with some treatments.

4. The hospital environment can be fraught with danger, for example, infection with a nosocomial infection of a person, insomnia due to being in a hospital

environment.

5. Personal circumstances of a person, for example, the low material wealth of the patient, which does not allow him to fully eat, which, in turn, may threaten his health.

After the assessment of the health status of the patient

I that nurse must formulate a diagnosis, decide who

of health care professionals

help the patient.

Problems that a nurse can prevent or solve on her own are called sisterlydiagnoses.

The nurse needs to formulate the diagnoses very clearly and establish their priority and significance for the patient.

The history of the issue began in 1973. The first scientific conference on the classification of nursing diagnoses was held in the USA in order to define the functions of a nurse and develop a system for classifying nursing diagnoses.

In 1982, in a textbook on nursing (Carlson Craft and McGuire), in connection with changes in views on nursing, the following definition was proposed.

Nursing diagnosis- this is the patient's state of health (current and potential), established as a result of a nursing examination and requiring intervention from the nurse.

In 1991 proposed a classification of nursing diagnoses, including 114 the main names, including hyperthermia, pain, stress, social self-isolation, insufficient self-hygiene, lack of hygiene skills and sanitary conditions, anxiety, reduced physical activity, and more.

In Europe, the initiative to create a pan-European unified classification of nursing diagnoses was made by the Danish National Organization of Nurses. In November 1993 1999, under the auspices of the Danish Research Institute for Health and Nursing, the 1st International Scientific Conference on Nursing Diagnosis was held in Copenhagen. More than 50 countries of the world participated in the conference. It was noted that unification and standardization, as well as terminology, still remain a serious problem. Obviously, without a unified classification and nomenclature of nursing diagnoses, following the example of medical sisters, they will not be able to communicate in a professional language that is understandable to everyone. The stage of making nursing diagnoses will be the completion of the nursing diagnostic process.

Nursing diagnosis should be distinguished from medical diagnosis.leg:

t medical diagnosis determines the disease, and nursing - is aimed at identifying the body's reactions to its condition;

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w the medical diagnosis may remain unchanged throughout the illness. Nursing diagnosis may change every day or even during the day as the body's reactions change;

medical diagnosis involves treatment within the framework of medical practice, and nursing - nursing interventions within its competence and practice;

a medical diagnosis is usually associated with the pathophysiological changes that have arisen in the body. Nursing - often associated with the patient's ideas about his state of health.

Nursing diagnoses cover all areas of a patient's life. Distinguish physiological, psychological,social and spiritual diagnoses.

There can be several nursing diagnoses, five or six, and most often only one medical diagnosis.

There are explicit (real), potential and priority nursing diagnoses. Nursing diagnoses, intruding into a single treatment and diagnostic process, should not dismember it. It is necessary to realize that one of the basic principles of medicine is the principle of integrity, that is, the understanding of the disease as a process that encompasses all systems and levels of the body (cellular, tissue, organ and body). Analysis of pathological phenomena, taking into account the principle of integrity, makes it possible to understand the contradictory nature of the localization of disease processes, which cannot be imagined without taking into account the general reactions of the body.

When making nursing diagnoses, the nurse uses knowledge about the human body obtained by various sciences. Therefore, the classification of nursing diagnoses is based on violations of the basic processes of the body's vital functions, covering all areas of the patient's life, both real and potential. This made it possible already today to distribute various nursing diagnoses into 14 groups. These are diagnoses associated with disruption of processes:

■ movements(decrease in motor activity, impaired coordination of movements, etc.);

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tons of attention(arbitrary, involuntary, etc.); w memory(hypomnesia, amnesia, hypermnesia);

thinking(decrease in intelligence, violation of spatial orientation);

changes in emotional and sensitive areas(fear, anxiety, apathy, euphoria, negative attitude to the personality of the medical worker providing assistance, to the quality of the manipulations, loneliness, etc.);

changes in hygiene needs(lack of hygiene knowledge, skills, problems with medical care, etc.).

Signs of a violation of the basic processes of the body's vital activity are anatomical, physiological, psychosocial and spiritual changes in a person's life.

Of particular importance in nursing diagnostics is the establishment of psychological contact, the determination of the primary psychological diagnosis.

Observing and talking with the patient, the nurse notes the presence or absence of psychological tension (dissatisfaction with oneself, a sense of shame, etc.) in the family, at work:

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t changes (dynamics) of the emotional sphere, the influence of emotions on behavior, mood, as well as on the state of the body, in particular, on immunity; ■ behavioral disorders that are not immediately diagnosed and are often associated with psychosocial underdevelopment, in particular, deviation from the generally accepted norms of physiological functions, abnormal eating habits (perverted appetite), incomprehensibility of speech are common.

The patient loses psychological balance, anxiety, illness, fear, shame, impatience, depression and other negative emotions appear, which are subtle indicators, motivators of the patient's behavior.

The nurse knows that primary, emotional reactions excite the activity of subcortical vascular-vegetative and endocrine centers.

Therefore, with pronounced emotional states, a person turns pale or blushes, changes in the rhythm of heart contractions occur, the temperature of the body, muscles decreases or rises, the activity of the sweat, lacrimal, sebaceous and other glands changes. In a frightened person, the palpebral fissures and pupils expand, blood pressure rises. Patients in a state of depression are inactive, retire, various conversations for them

painful.

Wrong education makes a person less capable of volitional activity: A nurse who has to take part in the education of a patient should take this factor into account, as it affects the process

assimilation.

Thus, a psychological diagnosis reflects the psychological disharmony of a patient who finds himself in an unusual situation.

Information about the patient is interpreted by the nurse and reflected in the nursing psychological diagnosis in terms of the patient's needs for psychological

For example, nursing diagnosis:

The patient feels a sense of shame before setting a cleansing enema;

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Pa Tsient experiences anxiety related to the inability to serve himself.

Psychological diagnosis is closely related to the social status of the patient. Both the psychological and spiritual state of the patient depends on social factors, which can be the cause of many diseases. Therefore, it is possible to combine psychological and social diagnostics into a psychosocial one. Of course, at present, the patient's problems are not fully resolved in psychosocial assistance, however, the nurse, taking into account the socio-economic information about the patient, social risk factors, can accurately diagnose the patient's reaction to his state of health. After formulating all nursing diagnoses, the Nurse prioritizes them, based on the patient's opinion about the priority of providing care to him.

For an example of a bank of patient problems, see Appendix No. 2.

stage of nursing diagnosis

NURSING DIAGNOSIS

any diagnoses or problems of the patient

As soon as the nurse has begun to analyze the data obtained during the examination, the second stage of the nursing process begins - the identification of the patient's problems and the formulation of the nursing diagnosis.

Patient problems- these are the problems that exist in the patient and prevent him from achieving a state of optimal health in any given situation, including the state of illness and the process of dying. At this stage, the nurse's clinical judgment is formulated, which describes the nature of the patient's existing or potential response to the disease.

The purpose of nursing diagnosis is to develop an individualized care plan so that the patient and his family can adapt to the changes that have arisen due to health problems. At the beginning of this stage, the nurse identifies the needs, the satisfaction of which is violated in this patient. Violation of needs leads to problems for the patient.

According to the nature of the patient's reaction to the disease and their condition, nursing diagnoses are distinguished:

1) physiological eg, undernutrition or overnutrition, urinary incontinence;

2) psychological , for example, anxiety about their condition, lack of communication, leisure or family support;

3) spiritual, problems associated with a person's ideas about his life values, with his religion, the search for the meaning of life and death;

4) social , social isolation, conflict situation in the family, financial or domestic problems associated with access to disability, change of residence.

Depending on the time, the problems are divided into existing and potential . Existing problems take place at the moment, these are problems "here and now". For example, headache, lack of appetite, dizziness, fear, anxiety, lack of self-care, etc. Potential problems do not currently exist, but may appear at any time. The occurrence of these problems must be foreseen and prevented by the efforts of medical personnel. For example, the risk of aspiration from vomit, the risk of infection associated with surgery and reduced immunity, the risk of pressure ulcers, etc.

As a rule, a patient has several problems at the same time, so existing and potential problems can be divided into priority- the most significant for the patient's life and requiring a priority decision, and secondary- the decision of which may be delayed.

Priority are:

1) emergency conditions;

2) problems that are the most painful for the patient;

3) problems that can lead to a deterioration in the patient's condition or the development of complications;

4) problems, the solution of which leads to the simultaneous solution of other existing problems;

5) problems that limit the patient's ability to self-care.

There should be few priority nursing diagnoses (no more than 2-3).

Diagnosis is designed to identify the problems that arise in the patient, the factors that contribute to or cause these problems.

Once the information is collected, it should be analyzed and the patient's explicit and implicit unmet care needs identified. The patient's ability to provide self-care, home care, or need for nursing intervention should be determined. To do this, a nurse needs a certain level of professional knowledge, the ability to formulate a nursing diagnosis.

Nursing diagnosis- this is a clinical judgment of a nurse, which describes the nature of the patient's existing or potential response to the disease and his condition (problems), indicating the reasons for such a reaction, and which the nurse can independently prevent or resolve.

The nurse asks the patient about:- past illnesses - the patient's attitude to alcohol; - features of nutrition; - allergic reactions to drugs, food, etc.; - the duration of the disease, the frequency of exacerbations; - taking medications (name of the drug, dose, frequency of administration, tolerability); - Patient's complaints at the time of examination. The nurse conducts an objective examination:- examination of the condition of the skin and mucous membranes; the color of the palms, the presence of scratching, "spider veins", dilated veins on the anterior abdominal wall; - determination of the patient's body weight; - measurement of body temperature; study of the pulse; - measurement of blood pressure; - assessment of the size of the abdomen (presence of ascites); - superficial palpation of the abdomen.

All data from the nursing examination are documented in the nursing history by filling out the “Primary Nursing Assessment Sheet”

2.2.2. Stage II of the nursing process - identifying the patient's problems.

Purpose: to identify the patient's difficulties and contradictions resulting from the inability to satisfy one or more needs.

The nurse examines the external reaction of the patient to what is happening to him and identifies the patient's problems.

Patient problems:

Valid (real):- pain in the lumbar region; - oliguria; - weakness, fatigue;

Headache; - sleep disturbance; - irritability; - the need to constantly take medications; - lack of information about the disease; the need to stop drinking alcohol; - lack of self-care. Potential:- CRF (chronic renal failure) - the risk of developing renal encephalopathy;

Possibility of becoming disabled.

2.2.3. Stage III of the nursing process - nursing care planning.

A nurse should be able to set specific goals and draw up a real care plan with motivation for each step (Table 1).

Table 1

The care plan must be recorded in the nursing documentation for the implementation of the nursing process.

2.2.4. IV the stage of the nursing process is the implementation of the nursing care plan.

The nurse follows the planned plan of care.

1. Conducting a conversation with the patient and his relatives about the need to strictly follow a diet with a restriction of animal fats and a sufficient amount of proteins, carbohydrates and vitamins. Give a reminder about nutrition (Appendix 2). Spicy, fried and pickled foods are prohibited. With the appearance of signs of renal encephalopathy - restriction of protein foods. Food is fractional, at least 4-5 times a day. The use of any alcohol is strictly prohibited. Diet control - predominantly dairy-vegetable fortified food using mainly vegetable fats.

2. Providing the patient with a ward regimen. In debilitated patients - bed rest, which provides general care and a comfortable position for the patient in bed. Limitation of physical activity. 3. Implementation of personal hygiene, careful care of the skin and mucous membranes in case of dryness, scratching and itching of the skin. 4. Informing the patient about drug treatment (drugs, their dose, rules of administration, side effects, tolerability).

6. Providing the patient with conditions for a good sleep. 7. Control over: - the patient's compliance with the diet, diet, motor regimen; - transfers to the patient; - regular intake of medicines; - daily diuresis; - body weight; - the condition of the skin; - symptoms of bleeding (pulse and blood pressure). 8. Preparation of the patient for laboratory and instrumental research methods. 9. Compliance with medical-protective and sanitary-epidemiological regimes.

10. Patient's motivation to fulfill doctor's orders and nurse's recommendations.

11. Monitoring the mental state of the patient.

Nursing Process

Nursing process is a method of evidence-based and practical actions of a nurse to provide care to patients.

The purpose of this method is to ensure an acceptable quality of life in illness by providing the maximum possible physical, psychosocial and spiritual comfort for the patient, taking into account his culture and spiritual values.

Currently, the nursing process is one of the main concepts of modern models of nursing and includes five stages:

Stage 1 - Nursing examination

Stage 2 - Identification of problems

Stage 3 - Planning

Stage 4 - Implementation of the care plan

Stage 5 - Evaluation

NURSING EXAMINATION

the first step in the nursing process

At this stage, the nurse collects data on the patient's health status and fills out the inpatient nursing card

The purpose of the examination of the patient - collect, substantiate and interconnect the received information about the patient to create an information database about him and his condition at the time of seeking help.

Survey data can be subjective or objective.

Sources of subjective information are:

* the patient himself, who sets out his own assumptions about his state of health;

* relatives and friends of the patient.

Sources of objective information:

* physical examination of the patient's organs and systems;

* Acquaintance with the medical history of the disease.

In the process of communication between a nurse and a patient, it is very important to try to establish the warm, trusting relationship necessary for cooperation in the fight against the disease. Compliance with some rules of communication with the patient will allow the nurse to achieve a constructive style of conversation and win the patient's favor.

The subjective method of examination is questioning. This is data that helps the nurse get an idea of ​​the patient's personality.

Questioning plays a huge role in:

Preliminary conclusion about the cause of the disease;

Assessment and course of the disease;

Assessing the self-service deficit.

Questioning includes anamnessis. This method was introduced into practice by the famous therapist Zakharin.

Anamnesis- a set of information about the patient and the development of the disease, obtained by questioning the patient himself and those who know him.

The question is made up of five parts:

Passport part;

Patient complaints;

Anamnesis morbe;

Anamnesis vitae;

Allergic reactions.

The patient's complaints provide an opportunity to find out the reason that made him see a doctor.

From the patient's complaints are distinguished:

Actual (priority);

Main;

Additional.

The main complaints are those manifestations of the disease that most disturb the patient, are more pronounced. Usually the main complaints determine the problems of the patient and the features of his care.

Anamnesis morbe (case history) - the initial manifestations of the disease, which differ from those that the patient presents when seeking medical help, therefore:

Clarify the onset of the disease (acute or gradual);

Then they find out what the course of the disease was, how painful sensations have changed since their onset;

Clarify whether studies were carried out before the meeting with the nurse and what their results are;

It should be asked: whether treatment was carried out earlier, with the specification of drugs that can change the clinical picture of the disease; all this will allow to judge the effectiveness of therapy;

Specify the time of onset of deterioration.

Anamnesis vitae (life story) - allows you to find out both hereditary factors and the state of the external environment, which may be directly related to the onset of the disease in this patient.

Anamnesis vitae is collected according to the scheme:

1. biography of the patient;

2. past illnesses;

3. working and living conditions;

4. intoxication;

5. bad habits;

6. family and sexual life;

7. heredity.

Objective examination:

Physical examination;

Acquaintance with the medical record;

Conversation with the attending physician;

Studying the medical literature on nursing.

An objective method is an examination that determines the status of the patient at the present time.

Inspection is carried out according to a specific plan:

General inspection;

Inspection of certain systems.

Examination methods:

Basic;

Additional.

The main methods of examination include:

General inspection;

Palpation;

Percussion;

Auscultation.

Auscultation - listening to sound phenomena associated with the activity of internal organs; is a method of objective examination.

Palpation is one of the main clinical methods of objective examination of the patient using touch.

Percussion - tapping on the surface of the body and assessing the nature of the sounds arising from this; one of the main methods of objective examination of the patient.

After that, the nurse prepares the patient for other scheduled examinations.

Additional studies - studies conducted by other specialists (example: endoscopic examination methods).

During a general examination, determine:

1. general condition of the patient:

Extremely heavy;

Medium severity;

Satisfactory;

2. position of the patient in bed:

active;

Passive;

Forced;

3. state of consciousness (five types are distinguished):

Clear - the patient specifically and quickly answers questions;

Gloomy - the patient answers questions correctly, but late;

Stupor - numbness, the patient does not answer questions or does not answer meaningfully;

Sopor - pathological sleep, consciousness is absent;

Coma - complete suppression of consciousness, with the absence of reflexes.

4. anthropometric data:

5. breathing;

Independent;

Difficulty;

free;

6. presence or absence of shortness of breath;

There are the following types of shortness of breath:

Expiratory - difficulty exhaling;

Inspiratory - difficulty breathing;

mixed;

7. respiratory rate (RR)

8. blood pressure (BP);

9. pulse (Ps);

10. thermometry data, etc.

Blood pressure is the pressure exerted by the speed of blood flow in an artery on its wall.

Anthropometry is a set of methods and techniques for measuring the morphological features of the human body.

Pulse - periodic jerky oscillations (impacts) of the artery wall during the ejection of blood from the heart during its contraction, associated with the dynamics of blood filling and pressure in the vessels during one cardiac cycle.

Thermometry is the measurement of body temperature with a thermometer.

Shortness of breath (dyspnea) - a violation of the frequency, rhythm and depth of breathing with sensations of lack of air or difficulty breathing.

IDENTIFICATION OF PATIENT PROBLEMS –

the second stage of the nursing process

The objectives of the second stage of the nursing process:

1. analysis of surveys;

2. determine what health problem the patient and his family are facing;

3. determine the direction of nursing care.

A patient's problem is a patient's health condition, established as a result of a nursing examination and requiring intervention from a nurse.

The main methods used to identify the patient's problems are observation and conversation. Nursing problem determines the scope and nature of care for the patient and his environment. The nurse does not consider the disease, but the external reaction of the patient to the disease.

Nursing problems can be classified as physiological, psychological, spiritual and social.

In addition to this classification, all nursing problems are divided into:

* existing - problems that bother the patient at the moment (for example, pain, shortness of breath, swelling);

* potential - these are problems that do not yet exist, but may appear over time (for example, the risk of pressure ulcers in an immobile patient, the risk of dehydration with vomiting and frequent loose stools).

Having established both types of problems, the nurse determines the factors that contribute to or cause the development of these problems, also reveals the strengths of the patient, which he can counter the problems.

Since the patient always has several problems, the nurse must establish a system of priorities, classifying them as primary, secondary, and intermediate. Priorities - this is a sequence of the most important problems of the patient, allocated to establish the order of nursing interventions, there should not be many of them - no more than 2-3.

The primary priorities include those problems of the patient, which, if left untreated, can have a detrimental effect on the patient.

Intermediate priorities are non-extreme and non-life-threatening needs of the patient.

Secondary priorities are the needs of the patient that are not directly related to the disease or prognosis (for example, in a patient with a spinal injury, the primary problem is pain, the intermediate is limitation of mobility, the secondary is anxiety).

Priority selection criteria:

1. All urgent conditions, for example, acute pain in the heart, the risk of developing pulmonary hemorrhage.

2. The most painful problems for the patient at the moment, what worries the most is the most painful and main thing for him now. For example, a patient with heart disease, suffering from attacks of retrosternal pain, headaches, swelling, shortness of breath, may point to shortness of breath as his main suffering. In this case, "dyspnea" will be a priority nursing problem.

3. Problems that can lead to various complications and deterioration of the patient's condition. For example, the risk of pressure ulcers in an immobile patient.

4. Problems, the solution of which leads to the solution of a number of other problems. For example, reducing the fear of an upcoming operation improves the patient's sleep, appetite, and mood.

Goals are divided into:

Long-term (strategic);

Short-term (tactical).

Goal structure:

Action - the fulfillment of the goal;

Criteria - date, time, etc.;

Condition - with the help of whom or what you can achieve a result.

To draw up a plan, the nurse needs to know:

Patient complaints;

Problems and needs of the patient;

General condition of the patient;

State of consciousness;

The position of the patient in bed;

Lack of self care.

From the patient's complaints, the nurse learns:

What worries the patient;

Makes an idea about the personality of the patient;

Makes an idea of ​​the patient's attitude to the disease;

Localization of the pathological process;

The nature of the disease;

Identifies the patient's current and potential problems and determines his needs for professional care;

Creates a plan for patient care.

CARE PLANNING

- the third stage of the nursing process

The objectives of the third stage of the nursing process:

1. based on the needs of the patient, highlight priority tasks;

2. develop a strategy for achieving the goals;

3. designate a deadline for achieving these goals.

After examining, identifying problems and identifying the patient's primary problems, the nurse formulates the goals of care, expected results and terms, as well as methods, methods, techniques, i.e. nursing actions that are necessary to achieve the goals. It is necessary, through proper care, to eliminate all complicating conditions for the disease to take its natural course.

During planning, goals and a care plan are formulated for each priority problem. There are two types of goals: short-term and long-term.

Short-term goals should be achieved in a short time (usually 1-2 weeks).

Long-term goals are achieved over a longer period of time, aimed at preventing recurrence of diseases, complications, their prevention, rehabilitation and social adaptation, and the acquisition of medical knowledge.

After formulating goals and drawing up a care plan, the nurse must coordinate with the patient, enlist his support, approval and consent. By acting in this way, the nurse orients the patient towards success, proving the achievability of goals and jointly determining ways to achieve them.

IMPLEMENTING THE CARE PLAN

- the fourth stage of the nursing process

The goal of nursing intervention is to do everything necessary to carry out the intended plan of care for the patient, identical to the overall goal of the nursing process.