Stage II of the nursing process: nursing diagnosis. Determining the patient's problem in the nursing process Stage 2 of the nursing process includes
The concept of a nursing diagnosis (nursing problem) was first officially recognized and legislated in 1973 in the USA. The list of nursing problems approved by the American Nurses Association currently includes 114 main items, including hyperthermia, pain, stress, social isolation, poor self-hygiene, anxiety, decreased physical activity and etc.
A nursing diagnosis is a patient's health condition determined as a result of a nursing examination and requiring intervention by the nurse. This is a symptomatic or syndromic diagnosis, in many cases based on patient complaints.
The main methods of nursing diagnosis are observation and conversation. The nursing problem determines the scope and nature of care for the patient and his environment. The nurse does not consider the disease, but the patient's external reaction to the disease. There is a difference between medical and nursing diagnosis. Medical diagnosis focuses on recognizing pathological conditions, and nursing is based on a description of patients’ reactions to health-related problems.
Nursing problems can be classified as physiological, psychological and spiritual, social.
§ Physiological, for example, insufficient or excessive nutrition, swallowing disorders, itchy skin, insufficient self-hygiene.
§ Psychological, for example, anxiety about one’s condition, lack of communication, family support
§ Spiritual – loneliness, guilt, need for holy communion.
§ Social – social isolation, conflict situation in the family, financial or everyday problems associated with becoming disabled.
In addition to this classification, all nursing problems are divided into:
§ Present - problems that bother the patient in currently(eg, pain, shortness of breath, swelling);
§ Potential are problems that do not yet exist, but may appear over time (for example, the risk of bedsores in an immobile patient, the risk of dehydration due to vomiting and frequent loose stools).
§ Priority – problems that should be solved first.
Since a patient always has several problems, the nurse must determine a system of priorities, classifying them as primary, secondary and intermediate.
Primary priorities include those patient problems that, if left untreated, could have a harmful influence on the patient.
Intermediate priorities are the patient's non-extreme and non-life-threatening needs.
Secondary priorities are the patient's needs that are not directly related to the disease or prognosis (for example, in a patient with a spinal cord injury, the primary problem is pain, the intermediate problem is limited mobility, the secondary problem is anxiety).
Priority selection criteria:
Ø All emergency conditions, e.g. sharp pain in the heart, the risk of developing pulmonary hemorrhage.
Ø The most painful problems for the patient at the moment, what worries him the most is the most painful and important thing for him now. For example, a patient with heart disease, suffering from attacks of chest pain, headaches, swelling, shortness of breath, can point to shortness of breath as his main suffering. In this case, “dyspnea” will be the priority nursing concern.
Ø Problems that can lead to various complications and deterioration of the patient’s condition. For example, the risk of developing bedsores in an immobile patient.
Ø Problems, the solution of which leads to the resolution of a number of other problems. For example, reducing fear of upcoming surgery improves the patient's sleep, appetite, and mood.
The next task of the second stage nursing process is the formulation of a nursing diagnosis - determining the patient’s response to the disease and his condition.
Unlike a medical diagnosis, aimed at identifying a specific disease or entity pathological process, the nursing diagnosis may change daily and even throughout the day as the body's responses to illness change.
Physiological:
Lack of self-care.
Fever
Weakness
Psychological:
Lifestyle changes.
Communication deficit
Changing family processes.
Lack of adaptation to the disease.
Lack of knowledge about the disease
Anxiety.
Social:
Loss of social production ties.
Loss of ability to work.
Isolation during hospitalization.
Material difficulties.
Spiritual:
Lack of self-realization.
Lack of life values (harmony, success).
5) Potential problems.
Risk side effects from the use of medications (anti-inflammatory, non-steroidal, glucocorticoids).
Risk of permanent disability.
Risk of complications (amyloidosis).
6) Priority problems.
Joint pain.
Limitation of physical activity.
Fear of joint puncture.
Problem: Lack of self-service.
Goal: The patient will have less difficulty in self-care.
The m/s will daily assist the patient in performing the morning toilet (washing, brushing teeth, shaving), and washing his face.
M/s will assist the patient in maintaining their hairstyle on a daily basis.
M/s will participate in feeding the patient 3 times a day (hold spoon, fork).
M/s, if necessary, will provide a vessel.
M/s will provide assistance in changing linen.
The M/s will encourage the patient to strive for self-care.
M/s will have a conversation with relatives and teach them the skills of caring for the sick.
Problem: Concern about changes in appearance, deformation of joints.
Goals: Short term: The patient will not focus on the appearance of the joint after one week.
Long-term: The patient will not experience anxiety at the time of discharge and will adequately assess changes in the joints.
Plan nursing intervention:
After agreement with the doctor, the doctor will explain to the patient the features of the course of the disease and the essence of changes in the joints.
M/s will try to divert the patient's attention from appearance joints, focusing on positive dynamics during the course of the disease (reduction of pain, etc.).
M/s will compliment the patient on her pleasant facial features.
M/s will teach the patient how to choose rational shoes.
Problem: Risk of side effects from the use of non-steroidal anti-inflammatory drugs.
Goal: The patient will not experience any side effects from the medication.
Nursing intervention plan:
The nurse will explain to the patient the need to use medications and the rules for taking medications.
M/s will strictly adhere to the dosage, time and frequency of taking medications.
M/s will inquire about tolerance daily. medicines.
M/s will inform the doctor if there are any signs of side effects.
Features of the nursing process in rheumatoid arthritis.
The main active element of the complex treatment of rheumatoid arthritis is kinesitherapy. Movements stimulate blood and lymph circulation and trophism of the articular apparatus, and can slow down or lead to the reverse development of the pathological process. The earlier the movement treatment is started, the better the therapeutic result. Due to the progressive nature and long duration of the process, kinesitherapy must be carried out for years, throughout life.
The main methodological rule during an exacerbation, regardless of the stage, is that diseased joints must be given rest. In case of severe exudative phenomena, the joint is given the appropriate position to prevent contractures. The position of the joints is changed several times a day.
If general state allows the patient to begin massage for those parts of the limb that are located proximal to the affected joints, as well as basic physical exercises and self-care movements.
For intact parts of the body, a complex of a small number of elementary gymnastic exercises is prescribed several times, and in the morning hygienic gymnastics.
The patient, if possible, should change the position of his body in bed many times during the day.
When the phenomena begin to subside, massage (light, stroking), active and passive movements in the affected joint are prescribed, at a slow pace, in the full possible range of movements, very carefully expanding the type of exercise and load.
In case of defeat upper limbs Exercises related to the life and profession of the patient are prescribed if the lower limbs- teach walking.
The more pronounced the pain and deformation of the joints, the more carefully you need to use movements, without waiting for the pain to completely subside.
It is imperative to carry out psychological work with the patient, trying to activate him and make him an interested participant in rehabilitation. The patient should know that in the subacute and chronic periods of the disease:
Kinesitherapy is absolutely necessary and has exclusively important for functional recovery.
As an exception to general rule, it is used despite low-grade fever, accelerated ESR and joint pain.
Regardless of others medicinal products kinesitherapy should be carried out continuously, daily, and, if necessary, multiple times a day and for a long time (months, years, whole life).
Exercises are performed with the expectation of moving the adjacent joints with the diseased one, or the remaining undamaged joints, to prevent the development of a pathological process in them.
In the second step of the nursing process, the nurse identifies the patient's problems. This stage may also be called
nursing diagnosis of the patient's condition. This nickname formulates the clinical judgment of the nurse, which describes the nature of the patient’s existing or potential response to the disease and his condition with the desired indication probable cause such a reaction. This reaction may be due to illness, changes environment, therapeutic measures, living conditions, changes in the patient’s dynamic behavior pattern, personal circumstances.
The concept of "nursing diagnosis" first appeared in the United States in the mid-1950s. It was officially adopted and enshrined in law in 1973. A list of nurse diagnoses is given in reference books. She must justify each diagnosis in relation to a specific patient.
The goal of nursing assessment is to develop an individualized plan of care so that the patient and family can adapt to changes caused by health problems. At the beginning of this stage, the nurse identifies needs whose satisfaction in this patient is impaired. Violation of needs leads to the patient developing problems, the classification of which is shown in Fig. 8.4.
All problems are divided into existing (real, actual), already present at the time of the examination, and potential (complications), the occurrence of which can be prevented provided that quality nursing care is organized.
As a rule, several problems are simultaneously registered in a patient, therefore both existing and potential problems can be divided into priority - the most significant
Problems
1
Existing Potential
Priority Secondary Priority Secondary
Physiological Psychosocial
Rice. 8.4. Determination of patient problems (nursing diagnostics)
tion)
important for the patient’s life and requiring a priority decision, and secondary - the decision of which can be delayed. The priorities are:
Problems that are most painful for the patient;
Problems that can lead to a deterioration in the patient’s condition or the development of complications;
Problems whose solution leads to the simultaneous solution of other existing problems;
Problems that limit the patient's ability to self-care.
Depending on the level of violated needs, the patient’s problems are divided into physiological, psychological, social and spiritual. However, due to her competence, a nurse is not always able to solve all types of problems, therefore in practice it is customary to divide them into physiological and psychosocial.
Physiological problems are pain, respiratory failure, high risk suffocation, heart failure, decreased gas exchange, hyperthermia (overheating of the body), ineffective thermoregulation, disturbance (disorder) of the body diagram, chronic constipation, diarrhea, disruption of tissue integrity, insufficient cleansing respiratory tract, reduced physical mobility, risk of disruption of integrity skin, risk of tissue infection, sensory changes (auditory, gustatory, muscular-articular, olfactory, tactile, visual).
Psychological problems there may be a lack of knowledge (about the disease, healthy way life, etc.), fear, anxiety, restlessness, apathy, depression, difficulty controlling emotions, lack of family support, communication, mistrust of medical personnel, lack of attention to the unborn child, fear of death, feelings of false shame, false guilt before loved ones due to his illness, lack external sensations, helplessness, hopelessness. Social problems manifest themselves in social isolation, anxiety about financial situation due to becoming disabled, lack of leisure time, concern for their future (employment, placement).
The presence of existing problems in patients contributes to the emergence of potential ones, which requires the nurse to constantly monitor the patient and carry out high-quality nursing measures to prevent them. Potential problems include risks:
The occurrence of bedsores, hypostatic pneumonia, the development of contractures in an immobile patient;
Violations cerebral circulation with high blood pressure;
Falls and injuries in patients with dizziness;
The occurrence of burns during a hygienic bath for a patient with sensitivity disorders;
Deterioration of the condition due to improper use of medications;
Development of dehydration in a patient with vomiting or frequent
loose stool.
After examining, identifying the patient's problems and determining priorities, the nurse moves on to the third stage of the nursing process - planning nursing care.
Planning nursing intervention
In the third stage of the nursing process, the nurse makes a plan nursing care behind the patient with the motivation for their actions. A generalized model of the care plan is presented in Fig. 8.5.
A nursing care plan is a detailed listing of the nurse's specific actions necessary to achieve nursing goals. Planning of nursing care is carried out with the mandatory participation of the patient. The measures of the plan must be clear to the patient, and he must agree with them. First, the nurse determines the goals of the intervention and their priority.
Creating a nursing care plan
priority for solving identified problems
Setting goals:
1) short-term;
2) long-term
Choosing a way to solve a goal
Justification of the method for achieving the goal
Written care instructions
Rice. 8.5. Setting goals and planning nursing interventions
A goal is an expected specific positive result nursing intervention for each of the patient's identified problems. The goals of care are subject to the following requirements;
Specificity, correspondence to the patient’s problem, for example, the goal “the patient will feel better” should not be formulated;
Reality, achievability - unrealistic goals should not be predicted;
Time frame for achieving the goal - there are two types of goals: short-term (less than 1 week) and long-term (weeks, months);
Formulation in terms of nursing (rather than medical) competence;
Presentation in terms understandable to the patient, his relatives, and others medical workers and service personnel.
The formulation of the goal of nursing care must indicate the action that needs to be performed, the time needed to perform the action, the place, distance, and the condition for performing the action. For example, the patient's priority problem is lack of swallowing. The goal in this case will be to ensure (action) a sufficient supply of fluid and food to the patient's body until swallowing function is restored (time) with the help of a probe (condition).
After setting a goal, the nurse makes a plan for achieving it. In doing so, she must be guided by standards of nursing practice that are designed to work in a typical situation, and not with a specific patient. Thus, when creating an individual plan of care, the nurse is required to be able to flexibly apply the standard to a real-life situation. She has the right to supplement the plan with actions not provided for by the standard if she can argue her point of view. As the plan is developed, the nurse completes the nursing process chart. You can use the form shown in table. 8.2, which allows for uniformity of completion, consistency, continuity and control over the quality of nursing care.
Purpose of the nursing process
The goal of the nursing process is to maintain and restore the patient's independence in meeting the basic needs of his body.
The goal of the nursing process is achieved by solving the following tasks:
Creation of a patient information database;
Identifying the patient's health care needs;
Designation of priorities in medical care;
Developing a plan of care and providing care to the patient according to his needs;
Determine the effectiveness of the patient care process and achieve the goal medical care of this patient
Stages of the nursing process
In accordance with the tasks to be solved, the nursing process is divided into five stages:
The first stage is a nursing examination.
Nursing examination carried out in two ways:
subjective.
A subjective examination method is questioning. This is data that helps the nurse gain an idea of the patient's personality.
objective.
Objective method is an examination that determines the patient’s current status.
Subjective examination:
Questioning the patient;
Conversation with relatives;
Conversation with ambulance workers;
Conversation with neighbors, etc.
Questioning
A subjective examination method is questioning. This is data that helps the nurse gain 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;
Self-care deficit assessment.
The question includes anamnessis. This method was introduced into practice by the famous therapist Zakharin.
Anamnesis is a set of information about the patient and the development of the disease, obtained by questioning the patient himself and people who know him.
The question consists of five parts:
Passport part;
Patient complaints;
Anamnesis morbe;
Anamnesis vitae;
Allergic reactions.
The patient’s complaints make it possible to find out the reason that forced him to see a doctor.
The patient's complaints include:
Current (priority);
Main;
Additional.
Main complaints- these are the manifestations of the disease that most worry the patient and are more pronounced. Typically, the main complaints determine the patient's problems and the characteristics of his care.
Anamnesis morbe
Anamnesis morbe - initial manifestations of the disease, different from those that the patient presents when applying for medical care, That's why:
Determine the onset of the disease (acute or gradual);
Then they find out what the course of the disease was, how the painful sensations from the moment of their occurrence;
They clarify whether studies were carried out before the meeting with the nurse and what their results were;
You should ask: has there been any previous treatment, specifying medications that may change clinical picture illness; all this will allow us to judge the effectiveness of therapy;
The time of onset of deterioration is determined.
Anamnesis vitae
Anamnesis vitae – allows you to find out how hereditary factors, and the condition external environment, which may be directly related to the occurrence of the disease in a given patient.
Anamnesis vitae is collected according to the following scheme:
1. patient’s biography;
2. previous diseases;
3. working and living conditions;
4. intoxication;
5. bad habits;
6. family and sex life;
7. heredity.
Objective examination:
Physical examination;
Getting to know medical card;
Conversation with the attending physician;
Studying medical literature on nursing.
Objective method is an examination that determines the patient’s current status.
The inspection is carried out according to a specific plan: general examination; inspection of certain systems.
Examination methods: basic; additional.
The main examination methods include:
General examination;
Palpation;
Percussion;
Auscultation.
Auscultation– listening to sound phenomena associated with activities internal organs; is a method of objective examination.
Palpation- one of the main clinical methods objective examination of the patient using touch.
Percussion– tapping on the surface of the body and assessing the nature of the sounds that arise; one of the main methods of objective examination of the patient.
The nurse then prepares the patient for other scheduled tests.
Additional Research – research conducted by other specialists (example: endoscopic methods examinations).
At general examination define:
1. general condition of the patient:
Extremely heavy;
Moderate;
Satisfactory;
2. position of the patient in bed:
Active;
Passive;
Forced;
3. state of consciousness (five types are distinguished):
Clear – the patient answers questions specifically and quickly;
Gloomy - the patient answers questions correctly, but late;
Stupor - numbness, the patient does not answer questions or does not answer meaningfully;
Stupor is a pathological sleep, there is no consciousness;
Coma – complete suppression of consciousness, with absence of reflexes.
4. anthropometric data: Anthropometry– a set of methods and techniques for measuring the morphological characteristics of the human body.
5. breathing;
Independent;
Difficult;
Free;
6. presence or absence of shortness of breath; differentiate the following types shortness of breath: Shortness of breath (dyspnea)– disturbance of the frequency, rhythm and depth of breathing with sensations of lack of air or difficulty breathing.
Expiratory;
Inspiratory;
Mixed;
7. frequency breathing movements(NPV)
8. arterial pressure(HELL); Arterial pressure- the pressure exerted by the speed of blood flow in the artery on its wall.
9. pulse (Ps); Pulse– periodic jerky oscillations (beats) 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.
10. thermometry data, etc. Thermometry– measuring body temperature with a thermometer
The goal of the first stage of the nursing process is to create information base about the patient.
The second stage is nursing diagnosis.
The goals of the second stage of the nursing process: analysis of the surveys performed; determine what health problem the patient and his family are facing; determine the direction of nursing care.
Goals of the second stage of the nursing process:
1. analysis of the surveys carried out;
2. determine what health problem the patient and his family are facing;
3. determine the direction of nursing care.
All patient problems are divided into:
Potential;
Current;
Primary - requiring provision emergency care;
Intermediate – not life-threatening;
Secondary – not related to this disease or forecast.
Each of the problems could be:
Somatic;
Psychological;
As soon as the nurse has begun to analyze the data obtained during the examination, the second stage of the nursing process begins - identifying the patient's problems and formulating a nursing diagnosis.
Patient problems- These are 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 family can adapt to changes caused by health problems. At the beginning of this stage, the nurse identifies needs whose satisfaction in this patient is impaired. Violation of needs leads to problems for the patient.
Based on the nature of the patient’s reaction to the disease and his condition, nursing diagnoses are distinguished:
1) physiological , for example, insufficient or excessive nutrition, urinary incontinence;
2) psychological , for example, anxiety about one’s condition, lack of communication, leisure or family support;
3) spiritual, problems associated with a person’s ideas about his life values, 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 becoming disabled, changing place of residence.
Depending on the time, problems are divided into existing And potential . Existing problems take place in this 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 exist at this time, but may arise at any time. The occurrence of these problems must be anticipated and prevented by efforts medical personnel. For example, the risk of aspiration of vomit, the risk of infection associated with surgical intervention and decreased immunity, the risk of developing bedsores, etc.
As a rule, several problems are simultaneously registered in a patient, so existing and potential problems can be divided into priority- those that are most significant for the patient’s life and require priority decision, and minor- the decision of which may be delayed.
The priorities are:
1) emergency conditions;
2) problems that are 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 whose solution 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 determine the problems the patient is experiencing and the factors contributing to or causing these problems.
Once the information is collected, it should be analyzed to determine the patient's overt and latent unmet care needs. It is necessary to determine the patient's ability to provide self-care, home care, or the need for nursing intervention. For this medical nurse need a certain level professional knowledge, ability to formulate a nursing diagnosis.
Nursing diagnosis- this is the clinical judgment of the 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.