Stage 5 of the nursing process includes. The nursing process consists of five main stages

Final fifth stage nursing process - assessing the effectiveness of care and correcting it if necessary. Stage goals:
- assess the patient's reactions to nursing care;
- evaluate the results obtained and summarize;
- issue a discharge summary;
- analyze the quality of assistance provided.
Care assessments are carried out not only on the day the patient is discharged from the hospital, but constantly, at every meeting: during rounds with the doctor, during procedures, in the corridor, dining room, etc. The patient's condition changes daily and even several times a day, which is not always caused by the nature of the disease and treatment. This may be due to relationships with roommates, medical staff, attitude towards procedures, news from home or from relatives. Monitoring the patient is also an action of nursing staff. It is necessary to notice the slightest changes in the condition or behavior of patients, considering behavior as one of the main assessment criteria. Each time there is contact with a patient, the nursing process occurs anew. For example, after surgery in the morning, a patient was unable to independently change his body position, and after 3 hours the nurse noticed that he was turning over without outside help. This is both new information about the patient, and evaluation criteria. Changes in the patient’s behavior and condition, reflecting positive dynamics, are another victory for the medical staff. Unfortunately, sometimes treatment and care are ineffective. For example, after completing the planned measures to reduce the temperature, a patient again complains of chills after receiving a drip infusion.
Not always and not all problems are recorded; more often (if they do not affect the course of the disease or prognosis) they are simply noted by the nursing staff and verbally passed on to the shift. Conversely, assessment and recording of estimated indicators of the patient’s condition in the department intensive care are carried out in our clinics every half hour or hour. If the patient requires increased attention on the part of the staff, the criteria for assessing their condition are entered into the duty notebook, discussed at the beginning of the working day at “five-minute meetings” and in the evening when the shift is handed over.
To conduct the final stage of the nursing process efficiently, you need to: know what aspect you want to evaluate; have sources of information important for assessment; clarify the evaluation criteria - the expected results that nursing staff want to achieve together with the patient.

Rice. Fifth stage of the nursing process

Assessment aspects

Evaluation stage is a mental activity. Based on the use of certain evaluation criteria, nursing staff will have to compare the existing results of care with the desired ones: evaluate the patient’s reaction and, on this basis, draw a conclusion about the results obtained and the quality of care. To objectively assess the degree of success of care, it is necessary:
- clarify the goal and expected result in the patient’s behavior or reaction to the disease or his condition;
- assess whether the patient has the desired reaction or behavior;
- compare the assessment criteria with the existing reaction or behavior;
- determine the degree of consistency between goals and the patient's response.

Criteria for evaluation

Evaluation criteria can be the patient’s words or behavior, data objective research, information received from roommates or relatives. For example, for edema, the assessment criteria may be weight and fluid balance; when identifying the level of pain, pulse, position in bed, behavior, verbal and nonverbal information, and digital pain rating scales (if used) (Table 15-1).
If the set goals are achieved, the patient’s problem is solved, the nursing staff must make an appropriate entry in the medical history, put the date the problem was resolved and their signature.
Sometimes the patient’s opinion about the actions taken plays a decisive role at the assessment stage.

Sources of assessment

The source of assessment is not only the patient. Nursing staff takes into account the opinions of relatives, roommates, and all team members involved in the treatment and care of the patient.
The effectiveness of all care is assessed when the patient is discharged, transferred to another health care facility, or to the pathology department in the event of death.
If necessary, the nursing action plan is revised or interrupted. When a goal is partially or completely not achieved, the reasons for failure should be analyzed, which may include:
- lack of psychological contact between staff and patients;
- language problems in communicating with the patient and relatives;
- incomplete or inaccurate information collected at the time of patient admission to the hospital or later;
- erroneous interpretation of problems;
- unrealistic goals;
- incorrect ways to achieve goals, lack of sufficient experience and professionalism in implementation concrete actions care;
- insufficient or excessive participation of the patient and relatives in the care process;
- reluctance to ask colleagues for help when necessary.

Actions of nursing staff in the absence of the effect of care

If there is no effect, the nursing process begins again in the same sequence.
Assessment allows staff not only to determine the patient's response to care provided, but also to identify strengths and weak sides his professional activity.

Registration of discharge summary

At the end of a patient's hospital stay, short-term care goals have often already been achieved. In preparation for discharge, a discharge summary is prepared, the patient is transferred under the supervision of a district nurse, who will continue care to address long-term goals related to rehabilitation and relapse prevention. The epicrisis provides for a reflection of all the care received by the patient in the health care facility. It records:
- problems present in the patient on the day of admission;
- problems that appeared during your stay in the department;
- the patient's reaction to the care provided;
- problems remaining upon discharge;
- patient’s opinion about the quality of care provided. Nursing staff who will continue to care for the patient after discharge have the right to revise the planned activities in order to quickly adapt the patient to home conditions.
A sample of filling out the epicrisis is presented in the NIB at the end of the chapter. Rules for preparing the discharge summary in the card nursing supervision for patient Korikova E.V. are given in the NIB at the end of the section.

Table. Examples of problems and criteria for assessing goal achievement

Table. Comparison of patient's goal and response to care provided

Table. An example of what a nurse should do if the goal of care is not achieved.

Is there a future for nursing process?

The problems that a healthcare professional solves when caring for patients are themselves fraught with tension, anguish and anxiety. If we add to this mistakes, blunders, human weaknesses, tests to which everyday life, then the overload of medical workers, their busy rhythm of life, and sometimes not being able to withstand the load will become clear. This can be avoided by good organization of work, made possible largely thanks to the introduction modern technology nursing - nursing process.
Many people think that the nursing process is a formalism, “extra paperwork” that there is no time to fill out. But the fact is that behind this is the patient, who in a legal state must be guaranteed effective, high-quality and safe medical care, including nursing.
A nurse is an equal member of the medical team, necessary for both a great surgeon and a brilliant therapist. In a number of healthcare facilities that are trying to improve nursing technologies, both understanding and support from doctors are noted, and without this innovation is impossible.
In practical health care institutions, “Nursing Patient Observation Cards” began to be kept. These examples show that it is not applied to everyone, more often than not to a geriatric, doomed, seriously ill patient. In practice, it is compact, designed for a professional and not so voluminous compared to the example you saw in this manual. The form of maintaining such a document is arbitrary: the map cannot be standard. Its value lies in the reflection of the work of this team of nurses, taking into account its characteristics and the specifics of the patients. Recording each action of a nurse to care for a specific patient in a nursing observation chart makes it possible to determine the volume and quality of care provided, compare the care provided with standards, and blame or justify the nurse if necessary. The absence of such a document showing the participation of nursing staff in the process of managing a particular patient in practical healthcare negates their responsibility for their actions.
Representatives of healthcare facilities that have introduced an experimental “Patient Nursing Observation Card” say that this is a chance to improve the quality nursing care, evaluate participation and show “your face” in the treatment process, solve a number of problems (primarily in favor of the nurse and the patient).
Health is a lot of work. Illness is always a big and difficult “adventure”. Monitoring its development, thoroughly studying the patient’s problems, and joyfully solving complex problems during treatment are the most important goals of a nurse’s work.
Implementation into work practice medical institutions new nursing technologies that involve a creative approach can ensure the further growth and development of nursing as a science and have an effective impact on the quality medical care, raise the importance and prestige of the profession in the healthcare system.

conclusions
- Fifth, The final stage nursing process - assessing the effectiveness of care and correcting it if necessary.
- The source of assessment is not only the patient, nursing staff takes into account the opinions of relatives, roommates, and all team members involved in the treatment and care of the patient.
- The patient’s words or behavior, objective research data, information received from roommates or relatives can be used as evaluation criteria. Patient behavior is one of the main criteria for assessing care.
- Assessment allows nursing staff not only to assess the patient's response to the care provided, but also to identify the strengths and weaknesses of their professional work.
- An assessment of the effectiveness of all care is carried out by nursing staff when the patient is discharged, transferred to another health care facility, or the pathology department when fatal outcome. Information obtained at the time of final assessment should be reviewed and recorded in the nursing discharge summary. Here, not only the amount of nursing care provided and the patient’s response to care is noted, but also problems that need to be addressed after the patient is discharged from the health care facility.
- Nursing staff who continue care after discharge have the right to review planned activities to quickly adapt the patient to home conditions.
- Maintaining a “Nursing Patient Observation Card” in practical healthcare is a chance to improve the quality of nursing care and evaluate the role of nursing staff in treating patients.

Fundamentals of nursing: textbook. - M. : GEOTAR-Media, 2008. Ostrovskaya I.V., Shirokova N.V.

The purpose of the fifth stage is to assess the patient’s response to nursing care, analyze the quality of care provided, evaluate the results obtained and summarize.

The sources and criteria for evaluating nursing care are the following factors:

§ assessment of the degree of achievement of the set goals of nursing care;

§ assessment of the patient’s response to nursing interventions, medical staff, treatment, satisfaction with the fact of staying in the hospital, wishes;

§ assessing the effectiveness of nursing care on the patient’s condition; active search and assessment of new patient problems.

The assessment is carried out by the nurse continuously, with a certain frequency, which depends on the patient’s condition and the nature of the problem.

For example, One patient will be assessed at the beginning and end of the shift, and another will be assessed every hour.

Assessment aspects:

§ Achieving goals regarding patient problems.

§ The emergence of new problems that require the attention of the nurse.

The fifth stage is the most difficult, since it requires the nurse to think analytically: the nurse compares the existing results with the desired ones, using evaluation criteria . The patient’s words and/or behavior, objective research data, and information from the patient’s environment can be used as evaluation criteria.

For example, in case of dehydration, water balance can be used as an evaluation criterion, and when determining the level of pain, the corresponding digital scales can be used.

If the problem is resolved, the nurse should reasonably document this in the nursing record.

If the goal was not achieved, the reasons for the failure should be determined and the necessary adjustments should be made to the nursing care plan. In search of an error, it is necessary to once again analyze all the sister’s actions step by step.

For example, Having casually collected information about the patient at the first stage and started training him on self-administration of insulin, the nurse unexpectedly found out that the patient suffers from a visual impairment and does not see the division on the syringe, and therefore cannot control the dose of insulin. The nurse should make a correction: advise the patient to purchase an insulin syringe pen, a syringe with an attached magnifying glass, or teach this to loved ones.

If necessary, the nursing action plan is reviewed, interrupted or changed. When the intended goals are not achieved, the assessment makes it possible to see the factors that hinder their achievement. If the final result of the nursing process fails, then the nursing process is repeated sequentially to find the error and change the nursing intervention plan.

A systematic assessment process requires the nurse to think analytically when comparing expected results with achieved results. If the goals are achieved, the problem is solved, then nurse certifies this by making an appropriate entry in the nursing medical history, signs and dates it.

Example No. 1. A 65-year-old patient experiences involuntary urine leakage drop by drop, occasionally in portions without the urge to urinate. He is a widower, lives with his son and daughter-in-law in 2 room apartment with all conviniences. He has one grandson, 15 years old, who loves his grandfather dearly. The patient is worried about returning home because he does not know how the family will react to his problem. The son and grandson visit their father every day, but he refuses to meet with them; he lies with his face turned to the wall all day and sleeps poorly.

The patient suffers from meeting the needs: EXCITING, BEING HEALTHY, BEING CLEAN, AVOIDING DANGER, COMMUNICATING, WORK. In this regard, the following problems can be identified:

1) urinary incontinence;

2) anxiety about one’s condition;

3) sleep disturbance;

4) refusal to meet with loved ones;

5) high risk violation of the integrity of the skin and the appearance of diaper rash in groin area.

PRIORITY PATIENT PROBLEM: urinary incontinence. Based on it, the nurse sets goals in working with the patient.

Short term goals:

a) by the end of the week the patient realizes that with appropriate treatment this painful phenomenon will decrease or go away,

6) by the end of the week, the patient realizes that with appropriate organization of care, this phenomenon will not create discomfort for others.

Long-term goals: The patient will be psychologically prepared for family life at the time of discharge.

1. The nurse will provide isolation for the patient (separate room, screen).

2. The nurse will talk with the patient about his problem every day for 5-10 minutes.

3. The nurse will advise the client not to limit fluid intake.

4. The nurse will ensure that a male urinal bag is always used at night and a removable urinal bag is used during the day.

5. The nurse will ensure that the urine bag is disinfected daily and treated with potassium permanganate solution, 1% hydrochloric acid solution, or 0.5% clarified bleach solution to eliminate the ammonia odor.

6. The nurse will monitor bed hygiene: the mattress will be covered with oilcloth, bed linen and underwear will be changed after each case of urination in the bed.

7. The nurse will ensure hygiene of the skin of the groin area (washing and treating with Vaseline or baby cream at least three times a day).

8. The nurse will ensure the room is ventilated at least 4 times a day for 20 minutes and the use of deodorizers.

9. The nurse will provide wet cleaning wards at least 2 times a day.

10. The nurse will observe the color, clarity, and odor of the urine.

11. The nurse will teach the patient's relatives about home care.

12. The nurse will provide sufficient time to discuss the patient's problems daily, focusing his attention on modern incontinence care products (removable urinals, absorbent panties and diapers with a deodorizing effect, means for preventing diaper rash). The nurse will familiarize the patient with the literature on this issue.

13. The nurse will talk with relatives about the need psychological support patient.

14. The nurse will encourage the patient's family to show attention to him without personal contact for several days (transfers, notes, flowers, souvenirs).

15. The nurse will encourage relatives to visit and inform them of appropriate behavior.

16. The nurse will provide admission sedatives and tranquilizers, as prescribed by a doctor.

17. The nurse will provide an introduction to the client who has urinary incontinence and is adjusted to his condition.

Questions for self-study

1. The essence of the third stage of the nursing process.

2. List the main components of the goal.

3. List the requirements for setting goals:

4. Explain how to properly plan nursing interventions.

5. The essence of the fourth stage of the nursing process.

6. List and describe the categories of nursing interventions:

§ independent,

§ dependent,

§ interdependent.

7. The essence of the fifth stage of the nursing process.

8. List the sources and criteria for evaluating nursing care.

Literature

Main sources:

Textbooks

1. Mukhina S.A. Tarnovskaya I.I. Theoretical basis Nursing: Textbook. – 2nd ed., rev. and additional – M.: GEOTAR – Media, 2008.

2. Mukhina S. A., Tarnovskaya I. I. “ Practical guide for the subject “Fundamentals of Nursing” Moscow Publishing Group “Geotar-Media” 2008.

3. Obukhovets T.P., Sklyarova T.A., Chernova O.V. Fundamentals of Nursing. – Rostov e/d.: Phoenix, 2002. – (Medicine for you).

4. Fundamentals of nursing: introduction to the subject, nursing process. ∕Compiled by S.E. Khvoshcheva. – M.: State Educational Institution VUNMC for Continuing Medical and Pharmaceutical Education, 2001.

5. Ostrovskaya I.V., Shirokova N.V. Fundamentals of Nursing: Textbook. – M.: GEOTAR – Media, 2008.

Additional sources:

6. Nursing process: Proc. manual: Transl. from English ∕Under general ed. Prof. G.M. Perfileva. – M.: GEOTAR-MED, 2001.

7. Shpirina A.I., Konopleva E.L., Evstafieva O.N. nursing process, universal needs human health and illness ∕Uch. A manual for teachers and students. M.; VUNMC 2002.

Lecture

Topic: “Nursing process, degrees of nursing process”

Nursing process– it is modern, scientifically sound and economically effective method organization and practical implementation of medical responsibilities for patient care.

JV is a new concept in medicine for the care and examination of a patient. This is a sequence of steps and components aimed at improving the results of care, the recovery of the patient or improving their well-being.

SP has 3 characteristics:

1) he must be patient-specific;

2) it should be focused on specific goal (recovery or improvement);

3) all steps must be interconnected.

The purpose of the SD is to increase the role of m/s, increase responsibility.

Nursing process It has 5 stages:

1) examination of the patient;

2) making a nursing diagnosis or identifying patient problems;

4) intervention or implementation of plans;

5) assessment.

Stage 1 - Examination of the patient.

The source of information can be the patient himself, relatives or people around him.

Information must be accurate and complete. The examination is carried out according to needs.

1) Physiological needs

· subjective

· objective

Subjective– this is what the patients themselves complain about or the feeling of being sick is experienced by the patient himself.

Objective– this is what m/s sees and identifies.

2) Psychological need– these are the patient’s internal experiences, fear, anxiety, identifying the attitude of patients towards their illness, the mood of patients is also divided into:

· subjective

· objective

3) Social need- This social conditions patients, life, working conditions, environmental data, finances, availability bad habits(smoking, alcohol, environmental pollution).

4) Spiritual need- this is thinking, beliefs, education, interests, hobbies, culture, customs, etc.

The m/s systematizes this data, briefly and clearly enters it into patient nursing care sheet.

Stage 2 – Identifying the patient’s problem.

This is an analysis of all the information received from the patient.

There are several problems.

Problem– this is everything that we find in a patient outside the norm (complaints, symptoms, deviations).

Stage 3 – Planning.

Installed priority of priority tasks that need to be addressed according to the severity of the problems.

Priorities are classified:

1) primary– which, if not eliminated, may have a detrimental effect on the patient (all types emergency care, high fever and heart attack, respiratory arrest, bleeding);

2) intermediate– not emergency and not life-threatening for the patient;

3) secondary– not directly related to the disease and prognosis.

Planning there is short-term and long-term.

Short term - these are those events that are held in a short period of time (before the first week).

Long-term aimed at preventing complications of the disease (weeks, months).

Plans can be moved or revised if there are no changes or results of the work performed.

Stage 4 – Intervention or implementation of the plan.

All activities are aimed at providing complete care for the patient, promoting health and preventing disease (any behavior or action of the sister is all aimed at fulfilling the plan).

Intervention There are dependent, interdependent, independent.

· Dependent is the fulfillment of medical prescriptions.

· Interdependent - depends on the doctor and m/s (joint work).

· Independent - includes those manipulations that the m/s performs independently (prevention).

Stage 5 – Assessment.

This is the result of nursing actions or how the patient responded to the intervention. Was the goal achieved, what was the quality of care.

· Improvement

· Recovery

· Without changes

· Tightening

· Deterioration

Death of the patient (fatal outcome)

The goal may be partially achieved or not achieved.

2. SD reforms. In practice (analysis)

2) VSO appeared in more than 22 Russian universities.

Nurses with higher education can work as chief physicians of nursing hospitals, chief and senior nurses of large hospitals.

3) The quality of work performed by nurses has changed (now nurses have more independence).

4) Thanks to the reform, public nursing organizations appeared.

Due to the fact that SD in Russia has lagged behind foreign countries in the pace and level of development since the 90s, SD reform has been underway in Russia.

Diplomas of nurses who have completed two years of education in foreign countries were not admitted.

The essence of the reform:

1) New programs have been introduced in the training of nurses - 3 years of study in colleges.

2) VZO more than 20 universities in Russia.

3) The Association of Russian Nurses was organized as public organization nurses.

4) Currently, the sisters have received greater independence and responsibility for their work.

5) Thanks to the reform, Russian nurses have international connections with other countries and with the World Health Organization (WHO).

In our Republic, college education has existed since 1993.

The Ministry of Health has the position of chief specialist for working with paramedical personnel.

Since 1995 – “SD” Magazine, 2000 – “Nurse”, “Medical Assistance”.

Lecture

Topic: “Nursing process: concepts and terms”

1. Introduction.

The term "nursing process" was first introduced by Lydia Hall in 1955. in USA.

The concept of “process” (from the Latin Processus - advancement) means a sequential change of actions (stages) to achieve a result.

Nursing process is a scientifically based technology of nursing care aimed at improving the patient’s quality of life through a systematic and step-by-step solution to the problems that arise.

Purpose of the nursing process contribute to the prevention, relief, reduction or minimization of problems and difficulties encountered by the patient.

The nursing process consists of 5 stages:

Stage 1 – nursing examination

Stage 2 – nursing diagnosis (identifying problems and making a nursing diagnosis)

Stage 3 – setting goals and planning care

Stage 4 – Implementation of the care plan

Stage 5 – assessment and correction of care if necessary.

Foundation nursing examination constitutes a doctrine of basic vital needs. A need is a physiological and/or psychological deficiency of something that is essential to a person’s health and well-being. In nursing practice, Virginia Henderson's classification of needs is used, which has reduced all their diversity to the 14 most important. TO Russian conditions adapted by Mukhina and Tarnovskaya 10 needs:

1. breathe normally

3. physiological functions

4. movement

5. sleep and rest

6. clothes: dress, undress, choose. Personal hygiene

7. maintain body temperature within normal limits

8. ensure your safety and not create danger for other people.

9. maintain communication with other people

10. work and rest.

2. Stage 1 – examination of the patient

The purpose of the stage is to obtain information to assess the patient’s condition or to collect and analyze objective and subjective data about the patient’s health.

The nurse obtains subjective data about the patient’s condition through questioning (conversation). The source of such information is, first of all, the patient himself, who shares his own ideas about the state of health and related problems. Subjective data depends on the patient's emotions and feelings.

The nurse receives objective data about the patient’s condition as a result of his examination, observation and examination. Objective data include the results of a physical examination of the patient (palpation, percussion, auscultation), measurement indicators blood pressure, pulse, breathing rate. Laboratory and instrumental studies refer to additional methods examinations.

Patient data must be descriptive, accurate and complete; they must not contain controversial provisions. The nurse enters the data obtained into the nursing care sheet (the patient's nursing history).

3. Stage 2 – nursing diagnosis

The purpose of the stage is to establish the patient’s existing and potential problems as a kind of reaction of the body to his condition, including illness;

Identify the reasons causing the development of these problems, as well as strengths patient that would help prevent or resolve them.

The nursing process consists of five main stages. FIRST STAGE – examination of the patient to collect information about the state of health. The purpose of the examination is to collect, substantiate and interconnect the information received about the patient in order to create an information database about him and his condition at the time of seeking help. the main role in the survey belongs to questioning. The collected data is recorded in the nursing medical record according to a certain form. A nursing medical history is a legal protocol document of the independent, professional activities of a nurse within the scope of her competence. SECOND STAGE – identifying the patient’s problems and formulating a nursing diagnosis. The patient's problems are divided into: main or real, concomitant and potential. The main problems are the problems that are bothering the patient at the moment. Potential problems are those that do not yet exist, but may appear over time. Related problems are not extreme or life-threatening needs and are not directly related to the disease or prognosis. Thus, the task of nursing diagnosis is to establish all current or possible future deviations from the comfortable, harmonious state, to establish what most burdens the patient at the moment is the main thing for him and try, within his competence, to correct these deviations. The nurse considers not the disease, but the patient's reaction to the disease and his condition. This reaction can be: physiological, psychological, social, spiritual. THIRD STAGE – nursing care planning. Plan of care Goal setting: Patient participation Standards of nursing 1. Short-term and family practice 2. Long-term FOURTH STAGE - implementation of the nursing intervention plan. Nursing interventions Categories: Patient need Methods of care: in assistance: 1. Independent 1. Temporary 1. Achieving therapeutic 2. Dependent 2. Permanent goals 3. Interdependent 3. Rehabilitative 2. Providing daily living needs, etc. FIFTH STAGE – assessment of the effectiveness of the nursing process. Efficiency of the nursing process Evaluation of actions Opinion of the patient Evaluation of the actions of the nurse by the nurse or his family by the head (senior and chief (personal) nurses) Evaluation of the entire nursing process is carried out if the patient is discharged, if he was transferred to another medical institution, if the patient died or in case of long-term illness. The implementation and implementation of the nursing process in health care facilities will help solve the following problems: Improve the quality and reduce the time of the treatment process without attracting additional funds; Reduce the need for medical personnel by creating “nursing departments, homes, Hospis” with a minimum number of doctors; Increase the role of the nurse in the treatment process, which is important for achieving a higher social status of the nurse in society; The introduction of multi-level nursing education will provide the treatment process with personnel with a differentiated level of training.

The nursing process consists of five stages (Fig. 19). This is a dynamic, cyclical process.

Rice. 19.

During the examination, the nurse collects the necessary information using a survey (structured interviewing). The source of data is: patient, relatives, medical workers, etc.

Before interviewing the patient, it is necessary to familiarize yourself with his medical documentation, if possible, recall factors and techniques that increase the effectiveness of communication:

? demonstrate the ability to introduce yourself;
? be able to carry on a conversation;
? check the correctness of your questions;
? set open questions;
? observe pauses and speech culture;
? apply individual approach to the patient.

Elements must be used effective communication with the patient and his environment.

Techniques such as communicating with the patient in an intelligent manner, a leisurely pace of conversation, maintaining confidentiality, and listening skills will increase the effectiveness of the interview and help the nurse improve her skills.

It is necessary not to make mistakes during the survey, not to ask questions that require a “yes” or “no” answer; clearly formulate your questions; remember that during the interview the patient can provide information about himself in any order; do not demand answers from him according to the scheme given in the nursing story. It is necessary to remember his answers and register them in strict accordance with the plan in the history of the patient’s health condition (illness); use information from the medical history (prescription sheet, temperature sheet etc.) and other sources of information about the patient.

The first stage of the nursing process - assessment of the patient’s condition (primary and current) using the nursing examination method consists of the following sequential processes:

? collection of necessary information about the patient, subjective, objective data;
? identification of disease risk factors, environmental data affecting the patient’s health status;
? assessment of the psychosocial situation in which the patient is;
? collection of family history;
? Analyze collected information to determine patient care needs.

Patient examination methods

To determine the patient's care needs and problems, the following examination methods are available: subjective, objective and complementary methods.

The collection of necessary information about the patient begins from the moment the patient is admitted to the medical facility and continues until discharge from the hospital.

The collection of subjective data is carried out sequentially in the following order:

? questioning the patient, information about the patient;
? patient's current complaints;
? the patient’s sensations, reactions associated with adaptive capabilities;
? collecting information about unmet needs associated with changes in health status or changes in the course of the disease;
? description of pain: its location, nature, intensity, duration, reaction to pain, pain scale.

Pain assessment carried out using non-verbal assessment of pain intensity using scales:

3) scale for characterizing pain relief:

the pain has completely disappeared - A, the pain has almost disappeared - B, the pain has decreased significantly - C, the pain has decreased slightly - D, there is no noticeable decrease in pain - E;

4) calm scale:
0 - no sedation;
1 - weak sedation; drowsy state, fast (light)

awakening;

2 - moderate sedation, usually a drowsy state, rapid

awakening;

3 - strong sedation, soporific effect, difficult to wake up

patient;

4 - the patient is sleeping, easy awakening.

The collection of objective data begins with an examination of the patient and an assessment of his physical characteristics. It is important to obtain information about the presence or absence of edema, measure height, and determine body weight. It is important to assess facial expression, state of consciousness, patient’s position, condition of the skin and visible mucous membranes, condition of the musculoskeletal system, and patient’s body temperature. Then assess the condition respiratory system, pulse, blood pressure (BP), natural functions, sensory organs, memory, use of reserves to alleviate health conditions, sleep, ability to move and other data.

It is important to identify risk factors and obtain information about the environment that affects the patient’s health.

Assessment of the patient's psychosocial state:

I the spheres of the psychological state are described: manner of speaking, observed behavior, emotional state, psychomotor changes, the patient’s feelings;

? socio-economic data are collected;
? disease risk factors are determined;
? The patient's needs are assessed and the violated needs are determined.

When conducting a psychological conversation, one should adhere to the principle of respect for the patient’s personality, avoid any value judgments, accept the patient and his problem as they are, guarantee the confidentiality of the information received, and listen patiently to the patient.

Monitoring the general condition of the patient

The nurse's job involves monitoring all changes in the patient's health status, timely allocation these changes, their assessment, and reporting them to the doctor.

When observing a patient, the nurse should pay attention to:

? on the state of consciousness;
? patient's position in bed;
? facial expression;
? color of the skin and visible mucous membranes;
? condition of the circulatory and respiratory organs;
? function of excretory organs, stool.

State of consciousness

1. Clear consciousness- the patient answers questions quickly and specifically.
2. Confused consciousness - the patient answers questions correctly, but late.
3. Stupor - a state of stupor, numbness, the patient answers questions late and thoughtlessly.
4. Stupor - pathological deep dream, the patient is unconscious, reflexes are not preserved, he can be brought out of this state with a loud voice, but he soon falls asleep again.
5. Coma - complete depression of central nervous system functions: no consciousness, muscles are relaxed, loss of sensitivity and reflexes (occurs with cerebral hemorrhage, diabetes mellitus, renal and liver failure).
6. Delusions and hallucinations - can be observed with severe intoxication ( infectious diseases, severe pulmonary tuberculosis, pneumonia).

Facial expression

Corresponds to the nature of the course of the disease, it is influenced by the gender and age of the patient.

There are:

? face of Hippocrates - with peritonitis ( acute stomach). He is characterized by the following facial expression: sunken eyes, pointed nose, pallor with cyanosis, drops of cold sweat;
? puffy face - with kidney diseases and other diseases - the face is swollen, pale;
? feverish face high temperature- bright eyes, facial hyperemia;
? mitral flush - cyanotic cheeks on a pale face;
? bulging eyes, trembling eyelids - with hyperthyroidism, etc.;
? indifference, suffering, anxiety, fear, painful facial expression, etc.

The patient's skin and visible mucous membranes

They may be pale, hyperemic, icteric, cyanotic (cyanosis), you need to pay attention to rash, dry skin, areas of pigmentation, and the presence of edema.

After assessing the results of monitoring the patient, the doctor makes a conclusion about his condition, and the nurse makes a conclusion about the patient’s compensatory capabilities and his ability to perform self-care.

Assessment of the patient's general condition

1. Satisfactory - the patient is active, facial expression is normal, consciousness is clear, the presence of pathological symptoms does not interfere with remaining active.
2. Condition of moderate severity - expresses complaints, there may be a forced position in bed, activity may increase pain, painful facial expression, expressed pathological symptoms from systems and organs, the color of the skin is changed.
3. Serious condition- passive position in bed, active actions performs with difficulty, consciousness may be altered, facial expression may change. Disturbances in the functions of the respiratory, cardiovascular and central nervous systems are pronounced.

A condition assessment is carried out to determine violated (unsatisfied) needs.

IN nursing documentation they need to be noted (underlined):

1) breathe;
2) there is;
3) drink;
4) highlight;
5) sleep, rest;
6) be clean;
7) dress, undress;
8) maintain body temperature;
9) be healthy;
10) avoid danger;
11) move;
12) communicate;
13) have life values - material and spiritual;
14) play, study, work.

Self-care assessment

The degree of independence of the patient in care is determined:

? the patient is independent when he performs all care activities independently and correctly;
? partially dependent, when care activities are performed partially or incorrectly;
? completely dependent when independent actions the patient cannot perform care and is cared for by medical staff or relatives trained by medical personnel.

Analysis of collected information

The purpose of the analysis is to determine the priority (by degree of threat to life) violated (unmet) needs or problems of the patient and the degree of independence of the patient in care.

The success of the examination, as a rule, depends on the ability to create trusting relationships with the patient and his environment and colleagues, effective communication in the process of professional activity, adherence to ethical and deontological principles, interviewing skills, observation, and the ability to document examination data.

The second stage of the nursing process is nursing diagnosis, or identifying the patient's problems.

Nursing diagnosis is recognized to establish:

? problems that arise in the patient and require nursing care and care;
? factors contributing to or causing these problems;
? the patient's strengths that would help prevent or resolve problems.

This stage may also have another name: “making nursing diagnoses.”

Analysis of the information received is the basis for formulating the patient’s problems - existing (real, obvious) or potential (hidden, which may appear in the future). When determining the priority of problems, the nurse must rely on the medical diagnosis, know the patient’s lifestyle, risk factors that worsen his condition, remember his emotional and psychological state and other aspects that help her accept responsible decision, - identifying patient problems or making nursing diagnoses with the goal of solving these problems through nursing care.

The process of formulating a nursing diagnosis or patient problem and then documenting it is very important and requires professional knowledge, skills to find connections between signs of deviations in the patient’s health status and the reasons that cause them. This skill depends, among other things, on intellectual abilities nurse

Concept of nursing diagnosis

The patient's problems, which are recorded in the nursing care plan in the form of clear and concise statements and judgments, are called nursing diagnosis.

The history of the issue began back in 1973. The I International Scientific Conference on the Classification of Nursing Diagnoses was held in the USA with the aim of defining the functions of a nurse and developing a classification system for nursing diagnoses.

In 1982, in a textbook on nursing(Carlson Kraft and Mac Hure) in connection with changes in views on nursing, the following definition is proposed:

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

In 1991, a classification of nursing diagnoses was proposed, including 114 main items, including: hyperthermia, pain, stress, social isolation, poor self-hygiene, lack of hygiene skills and sanitary conditions, anxiety, decreased physical activity, etc.

In Europe, with the initiative to create a pan-European unified classification nursing diagnoses were made by the Danish National Organization of Nursing. In November 1993, under the auspices of the Danish Research Institute of Health and Nursing, the First International Scientific Conference on Nursing Diagnoses 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. It is obvious that without a unified classification and nomenclature of nursing diagnoses, following the example of doctors, nurses will not be able to communicate in a professional language that is understandable to everyone.

The North American Association of Nursing Diagnoses (IAINA) (1987) has published a list of nursing diagnoses, which is determined by the patient's problem, cause of its occurrence and direction further actions nurses. For example:

1) anxiety associated with the patient’s anxiety about the upcoming operation;
2) the risk of developing bedsores due to prolonged immobilization;
3) dysfunction of bowel movement: constipation caused by insufficient consumption of roughage.

The International Council of Nurses (ICN) developed (1999) the International Classification of Nursing Practice (ICNP) - a professional information tool necessary to standardize the professional language of nurses, to create a unified information field, document nursing practice, record and evaluate its results, staff training, etc. d.

In the context of the ICFTU, a nursing diagnosis is understood as a nurse's professional judgment about a phenomenon related to health or social process representing the object of nursing interventions.

The disadvantages of these documents are the complexity of the language, cultural features, ambiguity of concepts, etc.

Today in Russia there are no approved nursing diagnoses.

The concept of nursing diagnosis is still new, however, as knowledge in the field of nursing increases, so does the potential for development of nursing diagnosis, so it is not so important what to call the second stage of the nursing process - identifying the patient's problems - nursing diagnosis, diagnosis.

Often the patient himself is aware of his actual problems eg pain, difficulty breathing, poor appetite. In addition, the patient may have problems that the nurse is not aware of, but she may also be able to identify problems that the patient is not aware of, such as a rapid pulse or signs of infection.

The nurse should know the sources possible problems patient. They are:

1) environment And harmful factors, affecting humans;
2) medical diagnosis patient or doctor's diagnosis. A medical diagnosis defines a disease based on special assessment physical signs, medical history, diagnostic tests. The task medical diagnostics is the prescription of treatment to the patient;
3) treatment of a person, which may have undesirable side effect, may itself become a problem, such as nausea, vomiting, with some types of treatment;
4) the hospital environment can be fraught with danger, for example, contracting a human nosocomial infection;
5) a person’s personal circumstances, for example, the patient’s low material income, which does not allow him to eat well, which in turn can threaten his health.

After assessing the patient's health status, the nurse must formulate a diagnosis, decide which of the professional workers healthcare can help the patient.

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

The stage of making nursing diagnoses will be the completion of the nursing diagnostic process.

Nursing diagnosis should be distinguished from medical diagnosis:

? a medical diagnosis determines the disease, and a nursing diagnosis is aimed at identifying the body’s reactions to health conditions;
? The doctor's diagnosis may remain unchanged throughout the illness. Nursing diagnosis may change daily or even throughout the day as the body's responses change;
? medical diagnosis presupposes treatment within the framework medical practice, and nursing - nursing interventions within its competence and practice;
? A medical diagnosis, as a rule, is associated with the pathophysiological changes that have arisen in the body, while a nursing diagnosis is often associated with the patient’s ideas about the state of his health.

Nursing diagnoses cover all areas of a patient's life.

There are physiological, psychological, social and spiritual diagnoses.

There can be several nursing diagnoses - five or six, but most often there is only one medical diagnosis.

There are obvious (real), potential and priority nursing diagnoses. Nursing diagnoses, invading a single diagnostic and treatment process, should not dismember it. It is necessary to realize that one of the basic principles of medicine is the principle of integrity. It is important for the nurse to understand the disease as a process that covers all systems and levels of the body: cellular, tissue, organ and organismal. Analysis of pathological phenomena taking into account the principle of integrity allows us to understand the contradictory nature of the localization of disease processes, which cannot be imagined without taking into account general reactions body.

When making nursing diagnoses, the nurse uses knowledge about the human body obtained from 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 has already made it possible to distribute various nursing diagnoses into 14 groups. These are diagnoses associated with process disorders:

1) movement (decrease motor activity, impaired coordination of movements, etc.);
2) breathing (difficulty breathing, productive and non-productive cough, suffocation, etc.);
3) blood circulation (edema, arrhythmia, etc.);
4) nutrition (nutrition significantly exceeding the body’s needs, deterioration of nutrition, etc.);
5) digestion (impaired swallowing, nausea, vomiting, constipation, etc.);
6) urination (urinary retention, acute and chronic, urinary incontinence, etc.);
7) all types of homeostasis (hyperthermia, hypothermia, dehydration, decreased immunity, etc.);
8) behavior (refusal to take medications, social isolation, suicide, etc.);
9) perceptions and sensations (hearing impairment, visual impairment, taste impairment, pain, etc.);
10) attention (voluntary, involuntary, etc.);
11) memory (hypomnesia, amnesia, hypermnesia);
12) thinking (decreased intelligence, impaired spatial orientation);
13) changes in the emotional and sensitive sphere (fear, anxiety, apathy, euphoria, negative attitude towards the individual medical worker providing assistance, to the quality of the manipulations performed, loneliness, etc.);
14) changes in hygiene needs (lack of hygienic knowledge, skills, problems with medical care and etc.).

Particular attention in nursing diagnostics is paid to establishing psychological contact and determining the primary psychological diagnosis.

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

? human movements, facial expressions, voice timbre and speech rate, lexicon provide a lot of varied information about the patient;
? changes (dynamics) 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, deviations from generally accepted norms of physiological functions, abnormal eating habits (perverted appetite), and incomprehensibility of speech are common.

The patient loses psychological balance, he develops anxiety, illness, fear, shame, impatience, depression and others negative emotions, which are subtle indicators and motivators of patient behavior.

The nurse knows that the primary emotional reactions stimulate the activity of subcortical vascular-vegetative and endocrine centers, therefore, in severe emotional states, a person turns pale or red, changes in heart rate occur, body and muscle temperature decreases or increases, the activity of the sweat, lacrimal, sebaceous and other glands of the body changes. In a frightened person, the eye slits and pupils widen, and blood pressure rises. Patients in a state of depression are inactive, seclude themselves, and various conversations are painful for them.

Improper upbringing makes a person less capable of volitional activity. A nurse who has to take part in teaching a patient must take this factor into account, as it affects the process of learning.

Thus, a psychological diagnosis reflects the psychological disharmony of a patient caught 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 care.

For example, nursing diagnosis:

? the patient feels a sense of shame before performing a cleansing enema;
? the patient experiences anxiety associated with the inability to care for himself.

Psychological diagnosis is closely related to the patient’s social status. Both the psychological and spiritual state of the patient depends on social factors, which can be the cause of many diseases, so psychological and social diagnostics can be combined into psychosocial ones. Of course, at present, the patient’s problems in psychosocial care are not fully resolved, however, the nurse, taking into account the socio-economic information about the patient and social risk factors, can quite accurately diagnose the patient’s reaction to his health condition. After formulating all nursing diagnoses, the nurse establishes their priority, based on the patient's opinion about the priority of providing him with care.

The third stage of the nursing process is determining the goals of nursing intervention

Setting care goals is necessary for two reasons:

1) the direction of individual nursing intervention is determined;
2) is used to determine the degree of effectiveness of the intervention.

The patient is actively involved in the goal planning process. At the same time, the nurse motivates the patient to succeed, convincing him of achieving the goal, and together with the patient determines the ways to achieve them.

For each dominant need, or nursing diagnosis, individual goals are written in the nursing care plan and considered as the desired outcome of care.

Every goal in mandatory includes three components:

1) execution (verb, action);
2) criterion (date, time, distance);
3) condition (with the help of someone or something).

For example: the patient will sit up in bed with the help of pillows on the seventh day.

Requirements for setting goals

1. Goals must be realistic and achievable.
2. It is necessary to set specific deadlines for achieving each goal.
3. The patient should participate in the discussion of each goal.

There are two types of goals based on timing:

1) short-term, the achievement of which is carried out within one week or more;
2) long-term, which are achieved within long period, more than a week, often after the patient is discharged from the hospital.

Short term:

1) the patient will not have suffocation after 20-25 minutes;
2) the patient’s consciousness will be restored within 5 minutes;
3) the patient will be stopped pain attack within 30 minutes;
4) the patient’s swelling will disappear lower limbs to the end of the week.

Long term:

1) the patient will have no shortness of breath at rest by the time of discharge;
2) the patient’s blood pressure levels stabilize by the tenth day;
3) the patient will be psychologically prepared for life in the family at the time of discharge.

The fourth stage of the nursing process is planning the scope of nursing interventions and implementing the plan

In nursing models where planning is the third stage, the fourth stage is implementation of the plan.

Care planning includes:

1) determining the types of nursing interventions;
2) discussing the care plan with the patient;
3) introducing others to the care plan.

According to the WHO definition, the implementation phase is defined as the implementation of actions aimed at achieving specific goals.

Requirements for implementing the plan

1. Systematically implement the plan within the established time frame.
2. Coordinate the provision of planned or unplanned nursing services, but provided in accordance with the agreed plan or not.
3. Involve the patient in the process of providing care, as well as his family members.

The nursing intervention plan is a written guide that details special actions nurses, including in the form of approved standards necessary to achieve nursing goals. The ability to apply the “standard” is the professional duty of a nurse.

There are three types of nursing interventions: dependent, independent and interdependent interventions.

Dependent are the actions of a nurse performed as prescribed by a doctor and under his supervision.

Independent The nurse carries out the actions herself, to the best of her competence. Independent activities include monitoring the response to treatment, the patient’s adaptation to the disease, providing pre-medical care, implementing personal hygiene measures, and preventing nosocomial infections; organization of leisure time, advice to the patient, training.

Interdependent are called the actions of a nurse to cooperate with other workers in order to provide assistance and care. These include actions to prepare for participation in instrumental and laboratory studies, participation in counseling: exercise therapy, nutritionist, physiotherapist, etc.

Requirements for determining the scope of nursing interventions

1. It is necessary to determine the types of nursing interventions: dependent, independent, interdependent.
2. Nursing interventions are planned based on the patient's impaired needs.
3. When planning the scope of nursing interventions, methods of nursing interventions are taken into account.

Nursing intervention methods

Nursing intervention methods can also be ways to satisfy disrupted needs.

Methods include:

1) provision of first aid;
2) fulfillment of medical prescriptions;
3) creation comfortable conditions for life activities in order to meet the basic needs of the patient;
4) providing psychological support and assistance;
5) performing technical manipulations;
6) measures to prevent complications and promote health;
7) organization of training and counseling for the patient and his family members.

Examples of nursing interventions

Dependents:

1) carry out doctor’s orders and report changes in the patient’s health status.

Independent:

1) monitor the response to treatment, provide first aid, carry out measures on personal hygiene, carry out measures to prevent nosocomial infections, organize leisure time, give advice to the patient, educate the patient.

Interdependent:

1) cooperation with other employees for the purpose of care, assistance, support;
2) consulting.

The fifth stage of the nursing process is assessing the results of nursing care

Final assessment of the effectiveness of the care provided and its correction if necessary.

This stage includes:

1) comparison of the achieved result with the planned care;
2) assessing the effectiveness of the planned intervention;
3) further evaluation and planning if the desired results are not achieved;
4) critical analysis of all stages of the nursing process and making necessary amendments.

The information obtained when assessing the results of care should form the basis for the necessary changes and subsequent interventions (actions) of the nurse.

The purpose of the summative assessment is to determine the outcome of nursing care and care. The assessment is ongoing, from assessment of the dominant need until the patient is discharged or dies.

The nurse constantly collects, critically analyzes information, draws conclusions about the patient’s reactions to care, real possibility implementation of the care plan and whether there are new problems that need attention. Thus, we can highlight the main aspects of the assessment:

? goal achievement;
? patient's reaction to nursing intervention;
? active search and assessment of new problems, violated needs.

If the goals are achieved and the problem is resolved, the nurse notes in the plan that the goal was achieved for this problem, puts the date, hour, minutes and signature. If the goal of the nursing process for this problem is not achieved and the patient still needs nursing care, it is necessary to reassess the state of his health in order to establish the reasons for the deterioration of the condition or the moment when no improvement in the patient’s condition occurred. It is important to involve the patient himself, and it is also useful to consult with colleagues regarding further planning. The main thing is to establish the reasons that prevented the achievement of the goal.

As a result, the goal itself may change, it is necessary to make changes to the nursing intervention plan, i.e. make care adjustments.

Evaluation of results and correction allows you to:

I determine quality of care;

? assess the patient's response to nursing interventions;
? identify new patient problems.