Sample of filling out the nursing process 5 stages. Brief description of the stages of the nursing process

Nursing diagnostics - II stage of the nursing process

The goals of a nursing diagnosis are to analyze the results of the assessment and determine what health problem the patient and family are facing and to outline a plan of nursing care.

After completing the patient's assessment, the nurse proceeds to determinenursing diagnosis. The Greek word for "discernment" for a physician means to determine the cause of suffering based on the identification of symptoms.

Nursing diagnosis - This is a thoughtful conclusion based on the analysis and interpretation of information obtained during the examination, it is discussed on the patient's health-related reactions, rather than on the recognition of diseases.

To understand the meaning and importance of nursing diagnosis, it is necessary to know the evolution of nursing diagnosis.

Discussion of this problem began in the 1930s in the USA. The medical literature on nursing contains many definitions of “nurse diagnosis.” Numerous articles have been published for and against the use of nursing diagnosis. These definitions have changed as the term nurse diagnosis has gained greater understanding among professionals. However, some common components of these definitions include the concept of "nursing", "patient and health problems". In addition, each definition implies clinical assessment and decision making.

In the 80s, activity in favor of nursing diagnostics increased, and in 1991. the nursing diagnosis was included in the Standards of Clinical Nursing Practice (USA). What is the difference between a medical diagnosis and a nurse’s diagnosis: (Table No. 4)

Medical (doctor's) diagnosis is a determination of the disease state based on a special assessment of physical signs, symptoms, and medical history. Medical diagnosis focuses on recognizing diseases.

Nursing diagnosis - this is a statement about actual or potential possible reaction patient for a disease (health problem) that the nurse is competent to treat. A nursing diagnosis reflects the patient's level of health or response to an illness or disease process. Doctor's diagnosis anddiagnosis nurses are established on the basis of physiological, psychological, socio-cultural, spiritual and other indicators of the patient’s examination.

Goals and objectives medical diagnosis - determine the disease and prescribe treatment.

Goals of nursing diagnosis - analyze the results of the examination and determine what health problem the patient and his family are facing, as well as outline a nursing care plan.

Nurse diagnostic task - development individual plan care for the patient so that the patient and his family can adapt to changes possible due to health problems.

Establishing a nursing diagnosis - this is the identification of the patient’s health problems.

Nursing diagnoses can be assigned to the patient, family, community, etc. and take into account the physical, intellectual, emotional (psychological), social and spiritual factors identified during the examination.

Structure of nursing diagnosis

Description of the patient's response to the disease

description of the possible reason for this reaction

Table No. 3

Second phase nursing process - nursing diagnosis - involves the following activities:

I . Processing information obtained during the examination

The nurse must be sure that the examination datacorrespond a certain diagnostic measure (standard, reference).

For example, when asking a patient about the nature of the pain, we obtain subjective information. However, palpation of the sore spot and the patient’s face distorted from pain is objective information.

Inattentiveness, haste, and irresponsibility of a nurse can lead to unwanted mistakes. These errors can occur at any stage of the nursing process: during examination and establishment of a nursing diagnosis, drawing up a nursing care plan, practical implementation plan and evaluation of results. American scientists Potter P. and Perry A. recommend some ways to avoid diagnostic errors:

Determine the patient's response to the disease.

Define diagnostic formulation.

Establish a cause that can be cured in the process of caring for the patient.

Determine the patient's need for a particular course of treatment or analysis.

Determine the patient's reaction to the equipment.

Understand the patient's problem, not the nurse's.

Understand the patient's problem, not the intervention.

Understand the patient's problem, not the goal.

Avoid harmful language.

Identify only one patient problem in the diagnostic formulation.

P. Identifying patient problems

After processing the information, the nurse identifies the patient's health problems.

Problems may be:

physical ( physiological )

psychological

social

spiritual

For example, incardiological A 70-year-old patient was admitted to the department with severe expiratory shortness of breath and headache, which she developed when she smelled gas. During the examination, the patient was restless, she was worried about the deterioration of her health, and shortness of breath began to occur every time the woman lit the gas stove, and did not go away for a long time. She also told the nurse that she lived alone, and there was no one at home to water the flowers; she was worried that they would dry out while she was in the hospital. The woman was also concerned that she was fasting now and whether she would be able to observe it while undergoing treatment.

Table No. 4

We identify the patient's problems.

Physiological - severe shortness of breath, headache.

Psychological - concerns about deteriorating health (attacks have become more frequent), worries about flowers (they will dry out).

Spiritual - fasting.

III. Formulation of nursing diagnoses

Once the patient's problems have been identified, nursing diagnoses must be formulated. The Association of American Nurses (AAM) has identified the main patient problems:

Limiting self-service.

Disturbances in sleep, rest, nutrition, sexuality, blood circulation, etc.

heart failure

nutritional disorder (low, high, etc.)

reduced gas exchange

3. Pain (discomfort)

chronic pain

chronic constipation

diarrhea

4. Emotional instability associated with illness health threatening and everyday life.

feeling of fear

feeling of despair, hopelessness

worrying about someone or something

excitement about...

indecision in decision making

lack of desire to take care of oneself

5. Impaired thinking

speech disorder

inadequate assessment of one's condition

situational loss of self-esteem.

Problems associated with life cycles(birth, death, stages of development)

Relationship problems

family conflicts

stressful situations

This is far from full list formulations of nursing diagnoses. The nurse must always remember that her task is not to define a disease, but to determine the level of health status or response to a disease or pathological process.

What nursing diagnoses can be made for the patient in our example?

Severe shortness of breath - impaired respiratory function, decreased gas exchange. Diagnosis:

"Worry about increased episodes of shortness of breath." Diagnosis:

"Worried about flowers left at home." Diagnosis:

"Anxiety about fasting." Diagnosis:

IV. Documentation

All established nursing diagnoses are recorded in the medical history - in the nursing process card. The nurse must clearly know the concept with which she defined the diagnosis so that there is no discrepancy, because the nursing process is carried out by different nurses.

The importance of nurse diagnosis and its application in creating a nursing care plan:

The use of nurse diagnosis is the mechanism by which the nurse's scope of care for the patient is established.

Diagnoses formulated by the nurseprovide direction to the planning process and the choice of treatment modality to achieve the desired results. Expected outcomes are predicted for each nurse diagnosis. The nurse's diagnosis and subsequent treatment plan for patient carehelp communicate patient concerns to other professionals with help treatment plan care, consultations, discharge plan and conferences on patient care issues.

Nurse diagnosisfacilitates the transfer of information between nurses.

The nurse's initial diagnosis list is an easily accessible reference for determining the patient's current treatment and nursing needs.

Nursing diagnoses alsoencourage the nurse to develop their organizational skills, for they help to give greater importance to the needs of the patient.

Nursing diagnoses are used to compile the nurse's notes on the progress of the patient's condition, to write referrals to a specialist doctor, to provide effective treatment and care for the patient when transferring him from one department to another, from one hospital to another. When planning the discharge of diagnosed patients, nurses provide a way to convey information and establish what treatment and care the patient still needs.

Nursing diagnoses can servecenter for quality assurance, improvement of nurse performance and joint reviews.

Quality assurance is the control and assessment of the quality and compliance of treatment and patient care in comparison with accepted standards. Improving the quality of a nurse's work is an assessment by professionals of how a nurse carries out her practical work, improves her qualifications, or participates in scientific research.By focusing on the nurse's diagnosis, the reviewer can determine whether the patient's treatment and care was appropriate and carried out in accordance with accepted standards of practice.

The nurse is responsible for his judgment and actions at all stages of the nursing process - from collecting data and assessing the patient's health conditions to assessing effectiveness and achieving set goals.

III stage of the nursing process - planning nursing interventions

Purpose: nursing planning: based on the needs of the patient, highlight priority tasks, develop a strategy for achieving goals, determine the criterion for their implementation.

Nursing assessment and formulation of nursing diagnoses represent a planning step in the nursing process. Planning is a category that defines nursing behavior in defining patient-centered goals and establishingstrategies to achieve goals.During planning:

priorities are set;

goals and expected results are determined;

patient care measures are selected;

possible consequences are established;

a nursing care plan is written.

1. Setting priorities

Once specific nursing diagnoses are established, the nurse determines priorities according to the severity of the diagnosis. Nursing priorities are established to determine the order in which nursing interventions are provided when a patient has multiple problems.

Prioritization is not simply a matter of listing nursing diagnoses according to their severity and psychosocial significance. Rather, it is a method in which the patient and nurse work together to make diagnoses based on the patient's wants, needs, and safety.

Table No. 5

Basic psychosocial needs are one step higher than safety needs. The needs for love, respect and self-expression may be given less attention. The nurse should be aware of situations where there are no emergency physical needs,But priority may be given to the psychological, sociocultural, developmental and spiritual needs of the patient.

Since the patient has several diagnoses, the nurse cannot begin to treat them simultaneously, after they are established. She chooses based on urgency, the nature of the prescribed treatment, and the interaction between diagnoses. Priorities are classified as:

primary

intermediate secondary

Table No. 6

Primary priority (leading importance) is given to the nursing diagnosis (or the patient’s condition, his reaction), implementationwhom requires urgent measures, since the patient’s condition and further treatment depend on the solution to this problem.

Let's turn to the nursing process map.

The nursing diagnosis of a feeling of “fullness” in the abdominal area due to prolonged stool retention is given primary priority, since after discussion with the patient the nurse made

the conclusion is that solving this particular problem is a priority task.

Intermediate Priority is given to diagnoses that do not require emergency measures.

In the case of our patient, these are the diagnoses:

High risk of recurrent constipation associated with poor diet and sedentary lifestyle.

Lack of care for your health.

High risk of chronic gastrointestinal diseases as a result of long-term persistent constipation.

Lack of knowledge about rational nutrition.

Secondary priority is the patient's needs that are not directly related to the disease and prognosis.

In our example there are no such ranges, and here the opinions of the patient and the nurse coincide. But the situation may be different. For example, a diagnosis of self-care deficits may be given secondary priority, but this should be a joint decision between the patient and the nurse.

Remember!

1. Care priorities are set to determine the order in which

nursing intervention is carried out.

2. This is not simply a listing of nursing diagnoses according to their severity and
psychosocial significance. This is a method in which the patient and nurse work together to make diagnoses based on the patient's wants, needs, and safety.

2. Defining goals and expected results

Goals and expected outcomes are identified by examining the patient's behavior or response based on the nurse's experience in nursing. After examining, diagnosing, and determining the patient's primary needs, the nurse formulates goals and expected results for each patient. established diagnosis together with the patient.

There are two reasons for writing goals and expected results.

First, goals and expected outcomes provide direction for individual nursing care.

Second, goals and outcomes are used to determine the effectiveness of aid.

The purpose of this work is to determine the patient's response to nursing care.

Each goal and each expected result must be allocated time for evaluation. The time allotted depends on the nature of the problem, etiology, general condition patient and prescribed treatment.

Since each patient reacts differently to different life situations Therefore, nursing diagnoses and care goals will be unique (inimitable, individual).

Patient-centered goals require the patient's active participation in defining them, defining expected outcomes, and determining the plan of care.

Goals must be realistic and achievable.

Goals should be specific, not vague, and general formulations should be avoided (“the patient will feel better,” “the patient will not feel discomfort,” “the patient will be adopted”).

The goal should be formulated within the limits of nursing, not medical competence.

Goals must have specific deadlines for their achievement.

The purpose must be clear to the patient, his family, and other health care professionals.

The patient should be maximally involved in the process of planning and implementing programs to protect his health. He has every moral right to obtain the information necessary to make serious decisions, to contribute to the assessment of the advantages and disadvantages of choosing treatment options, to accept, refuse or continue treatment without coercion. Every nurse must be competent in the moral and legal rights of the patient and must protect and support these rights. If the patient is not able to make an independent decision, then it is necessary to find someone who could do this (relatives, guardians). The nurse should also be aware of those situations c. whose individual rights to independence in the field of health care may temporarily fade into the background in order to protect society (for example, if an illness requires isolation of the patient from society or the sick person poses a direct threat to others - sharp forms psychoses, especially dangerous infections, etc.).

Goals should not only meet the immediate needs of the patient, but also include disease prevention and rehabilitation measures.

There are two types of goals allocated for patients: short-term and long-term.

Short term are goals that must be completed in a short period of time, usually less than a week.

Long-term are goals that can be achieved over a longer period of time, usually weeks and months (during hospital stay, upon discharge, after discharge). These goals are usually aimed at preventing complications, rehabilitation, and acquiring knowledge about health.

Let's return to the nursing process map.

To solve real problem No. 1 - “a feeling of fullness in the abdomen due to prolonged retention of stool”, two goals have been identified:

short term goal - the patient will empty the intestines on the day of hospitalization with an enema given by the nurse;

long term goal - independent bowel movement by the patient at the time of discharge.

Two other goals:

short-term goal - within a week the patient will receive information about rational nutrition as a result of conversations with a nurse;

long-term goal - by the time of discharge the patient will master exercise therapy complex and self-massage as a result of constant training with a physical therapy instructor, which allows you to solve all the patient’s acute problems.

When writing goals, the following mandatory points must be indicated:

Event – action . For example, the patient will empty the intestines on his own
will empty the intestines, receive information, master the complex of exercise therapy and self-massage.

Criterion - number, time, distance. For example, on the day of hospitalization, by the time
discharge, within a week, by the time of discharge.

Condition - assistant, assistant, etc.

For example, with the help of an enema given by a nurse; on one's own; as a result of classes with a physical therapy instructor.

Ultimately, the goal leads to the definition of expected results.

Expected results .

The expected result is a special, stepwise concept that leads to achieving the goal. The result is a change in the patient's behavior in response to nursing care. The results mean changes in the patient’s condition in terms of physiology, sociology, emotional and spiritual state. This change is detected through observation of the patient's reaction.

Planned before the nurse's action planning, O.R. set the direction nursing activities.

O.R. stem from short- and long-term patient-centered goals and are based on nursing diagnoses. When writing O.R. The nurse must make sure that the result is indicated in proportion to the norms of behavior. They must be compiled sequentially, taking into account time. This will help establish the order of nursing interventions as well as the timing of problem resolution.

Variety of O.R. are determined for each goal and each nursing diagnosis. The reason for emphasizing the variety of expected outcomes is the ability to resolve multiple patient problems with a single nursing action.

(see nursing process map)

O.R. determined when patient-centered goals are achieved. Sister uses O.R. as a criterion for assessing the effectiveness of the sister’s activities.

To avoid typical mistakes When writing goals and expected results, you must follow the basic rules:

1. C&R should focus on the patient and his behavior and reactions, rather than on nursing intervention .

It would be correct to define CIR as follows: “the patient will empty the intestines on the day of hospitalization with the help of an enema given by the nurse.”

It is incorrect to define CiR as follows: “to alleviate the patient’s condition with the help of an enema.”

2. C&R must be set in such a way that they can be assessed: observed, measured.

3. C&R must be real, since each goal achieved instills in the patient confidence in his speedy recovery. To do this, the nurse needs to know the health care resources, the family, and the patient.

3. Selection of measures according to nursing

This is the determination of the scope and methods of nursing care (nursing intervention). There are 3 categories of nursing interventions. The choice of category is based on the needs of the patient. One patient may have all three care plan categories, while another patient may only have an independent or interdependent care plan category.

1. Independent intervention. This intervention does not require outside supervision or direction. For example, interventions to increase patient knowledge about adequate nutrition or daily activities related to hygiene, massage, relaxation therapy, is an independent action of the nurse.

Independent interventions can resolve a patient's problems without consultation or collaboration with physicians or other health care providers. employees. They do not require instructions from a doctor or other specialists.

2. Interdependent intervention. These interventions are carried out by the nurse with another health worker. An example would be the use of hyperintensive treatment, in which the nurse has criteria by which drug and dietary therapy can be modified.

This cooperation can be defined as a partnership in which the value of the two parties is equally valued by both parties, common and separate areas of activity and responsibility are also recognized and accepted, mutual respect for the interests of both parties and also goals that are recognized by both parties.

3. Dependent intervention. These interventions are based on instructions or written instructions. Management of treatment, use of procedures, changing dressings, and preparing the patient for diagnostic tests are dependent nursing interventions.

Prescribing various treatments is not within the scope of nursing practice, but the nurse is responsible for carrying out the prescribed treatments.

Each dependent intervention requires responsibility and accurate knowledge. When managing treatment, the nurse must know the classification of drugs, their effects, dosage, side effects, nursing interventions related to their effects and side effects.

When applying procedures or changing dressings, the nurse must be sure when the procedures are needed (indications), have the skills necessary to perform them, and anticipate the expected result and possible side effects.

When ordering a diagnostic test, the nurse must plan its implementation, prepare the patient, and identify nursing applications.

All interventions require the nurse to evaluate and make a decision. When asked to perform a nursing intervention, the nurse should not automatically carry it out, but must determine whether the order is necessary for the patient. Every nurse encounters unnecessary and incorrect assignments from time to time. A nurse with a good knowledge base will recognize the error and find an explanation, because... an error may occur when writing an instruction or when it is reflected in a patient’s card. It is the responsibility of the nurse to clarify the instructions. A nurse who carries out an incorrect or unnecessary order is just as mistaken as the one who wrote it, and is also responsible for the consequences of the error.

Using the example of a nursing process map, we will try to determine what categories of interventions the care plan has.

TO independent factors include:

1. Motor activation of the patient (if the professional nurse has necessary knowledge);

2. Explanation of the principles of rational nutrition.
TOdependent factors include:

Providing dietary nutrition

Administration of enemas, use of physiotherapy

Introduction of herbal medicines into the diet

Purpose medicines

Nursing care planning involves cognitive and written processes. The individual plan of care is the result of the nurse's knowledge and research as well as the knowledge and research acquired from the consultants.

A nursing care plan is a written guide for patient care. It reflects the patient's health problems as determined through examination, nursing diagnoses, priorities, goals, and expected outcomes developed through the planning process.

Writing a plan allows you to:

1. Reduce the risk of incorrect care

In hospitals and other health care settings in the United States, a patient often receives care from more than one nurse, doctor, or outside specialist. A written plan of care provides an opportunity to coordinate the plan, conduct consultations, and schedule diagnostic tests.

Allows the other sister to continue care, since the plan's activities can
be performed throughout the day or day after day.

Nurses exchange information.

Nurses create their reports based on the nursing care and treatment provided in the care plan. After sharing information, nurses discuss the patient's care plans with those who will continue to care. This way, all nurses are able to discuss current and well-researched information about the patient's plan of care.

4. Carry out rehabilitation after discharge.

A written patient care plan also addresses the patient's needs after leaving the hospital. This is especially important for the patient, as he will go through a long course of rehabilitationV society (after surgical interventions, etc.).

The result of complete and accurate nursing care planning is the individualization, coordination and continuation of nursing care. Planning sets the framework for nursing care that must be followed.

IV stage of the nursing process - implementation of the nursing care plan

Do everything necessary to carry out the patient's plan of care (identical to the overall goal of the nursing process).

Execution or implementation are activities aimed at:

Help with illness.

Prevention of diseases and complications.

Health promotion.

In theory, implementation of the nursing care plan follows planning, but in practice, implementation may begin immediately after the assessment.

It is sometimes necessary to resort to immediate implementation when there is a threat to the physical, psychological and spiritual state of the patient.

Execution is a category of nursing behavior in which the actions necessary to achieve the expected outcome of nursing care are carried out until completion.

Giving help

managing activities in daily life

education and counseling of the patient and his family

providing direct assistance in the interests of the patient

assessment of the work of medical staff

recording and sharing information

Table No. 7

After plan care has already been developed and definedIstage of nursing care, the nurse begins to perform, i.e. carries out one or another nursing intervention.

Nursing intervention is any action of the m/s that carries out a nursing care plan or any task.this plan. Nursing care can be dependent, independent, interdependent (see.III step). In addition, nursing interventionscan be entirely based on protocols and guidelines.

Protocol is a written plan that precisely defines the procedures to be performed during the examination.

Note - this is a document containing rules, procedures, regulations for the provision of patient care. Directions have been approved and signed by the attending physician prior to use. They are typically used in intensive care units where patient needs can change rapidly and require special attention. The instructions also apply in medical institutions where it is not possible to immediately consult a doctor.

Directives and protocols give the nurse legal protection to intervene in the best interests of the patient. The nurse's responsibility is equal for all types of interventions.

Execution Methods

There are various methods of nursing. To achieve her goals, the nurse makes choices fromthe following methods:

Help with activities related to living needs.

Advice and instructions for the patient and his family.

Nursing care to achieve therapeutic goals.

Nursing care to facilitate the achievement of patient treatment goals.

5. Supervise and evaluate the performance of other staff members.

To achieve the goals of patient care, regardless of the methods used, the m/s must have theoretical knowledge, practical skills and communication skills with the patient and his relatives.

What exactly does each of these methods involve?

1. Assistance in performing activities related to life n y needs.

This is an activity, associated with daily needs, usually carried out during the day and includes eating, dressing, washing, serving the bed, etc.

The patient's need for help can be temporary, permanent or rehabilitative.

In cases of temporary care - such assistance is required for a short time, for example, with a fracture upper limbs the patient will need assistance until the cast is removed.

A patient who is unable to self-care due to damage to the cervical spine will have a constant need for help.

Rehabilitation will help the patient acquire new skills to perform daily needs to become more independent and capable of self-care.

2. Advice and instructions for the patient and his family

Advice is emotional, intellectual and psychological help. Advice, as a method of implementation, helps the patient adapt to new living conditions, cope with problems, stress and facilitates interpersonal relationships between patients, families and staff. Advice is very closely related to teaching. Education (instructions), as a method of implementation, is used to inform patients about their health status and to enable patients to acquire the necessary self-care skills. The nurse is responsible for determining the need for patient education and the quality of instructions given.

3. Patient care to achieve therapeutic goals

To achieve treatment goals, the m/s undertakes interventions to:

a) saving the patient’s life (resuscitation measures, containment of violent
patient, etc.);

b) compensation for adverse reactions caused by procedures, medications, and diagnostic tests.

For example, the patient previously had an intolerance or allergic reaction to the injection vitamin preparations. In this case, the m/s must:

stop administering medications;

write down symptoms, if any;

Tell your doctor and administer antihistamines as prescribed.

c) preventive measures.

They are aimed at preventing complications or exacerbations of the disease. For example, preventive measures when an allergic reaction is detected:

note in the medical history intolerance to vitamin preparations;

notify the patient and his family;

advise the patient what he should do when re-prescribing these drugs.

4. Patient care to facilitate the achievement of patient treatment goals

These are measures aimed at creating a favorable environment for the patient, i.e. compliance with the medical and protective regime.

The earliest stage of creating the necessary environment will be, for example, when a patient enters the hospital it is necessary to:

escort to the ward;

introduce service personnel and other patients;

introduce the daily routine and structure of the department;

provide privacy for performing hygiene needs, etc.;

Encourage and approve the slightest efforts of the patient aimed at recovery.
Nursing and others therapeutic measures designed for the needs of the patient,

Care plans should be flexible, allowing the patient to have choice.

5. Observe and evaluate the performance of other staff members

The nurse developing the plan of care often does not perform all interventions herself. Some of them are entrusted to other employees (junior nurses, nursing assistant, etc.). But the nurse is responsible for the quality of the measures performed.

V stage of the nursing process - assessing the achievement of goals

and expected results

The goal is to determine the extent to which results have been achieved.

Grade - This The final stage nursing process, which involves three different aspects:

Assessing patient responses to intervention. Patient's opinion about the intervention.

Assessment of achievement of set goals.

Assessing the quality of assistance provided. Impact of the intervention on the patient.

The assessment is performed continuously while the nurse interacts with the patient. The focus is on improving the patient's condition.

What does each aspect of this stage of the nursing process entail?

Assessing patient responses to nursing interventions.

Patient's opinion about the intervention.

While caring for a patient, the nurse compares the results achieved. For example, reducing pain symptoms, improving knowledge about your disease, etc.

The comparison is carried out together with the patient, and the results are based on his opinion.

2. Assessment of achievement of set goals.

Nursing care is needed to help the patient solve his health problems, prevent potential problems and maintain his health. The score shows whether the goal has been achieved.

For example, during the examination the patient feels severe pain in the stomach, holding his stomach with his hands, a grimace of pain on his face. The nurse uses these basic indications to determine a nursing diagnosis, set goals, plan care, and carry out interventions. After nursing actions have been performed, the nurse reassesses the patient's condition by observing the patient's response. For an objective assessmentdegrees Successful in achieving goals, the nurse should do the following:

Check the stated goal to determine the patient's exact wishes regarding his

Behaviors or reactions.

Assess the patient for this behavior or reaction.

Compare target criteria with behavior or response.

Determine the degree of consistency between target criteria and behavior or

Reaction.

Table No. 8

3. Assessing the quality of nursing care.

This aspect of evaluation is to measure the quality of nursing care.

Evaluation criteria are simply the evaluation skills and techniques used to collect data for evaluation. This assessment consists of the patient's opinion or reaction to the quality of care provided and the presence of complications for the intervention.

The evaluation is considered positive when the goals and expected results are achieved, negative if the results are undesirable or potential problems have not been avoided. In this case, the nurse must change the care plan and the nursing process is renegotiated. This coordination continues until all problems are resolved.

Let's look at options for achieving goals using the following examples. See Appendix No. 1 and the nursing process map.

After making sure that the expected results and goals have been achieved, the nurse addresses these assessments to the patient, if he agrees, the nurse interrupts this branch of the care plan. If goals are not achieved or are partially achieved, it is necessary to identify factors that impede the achievement of goals and eliminate them.

When hospitalization ends, many patients are discharged before all goals have been achieved and all problems have been resolved.

Importance of the nursing process

The nursing process improves the quality of care;

Maintains communication between medical staff;

Encourages nurses to improve their level of professional training;

Performs constant monitoring of the patient;

Medical staff treats the patient as an individual;

Thanks to the nursing medical history, it is easier to assess the quality of the nurse’s work and her competence;

The patient, nurse, and environment become participants in the nursing process.

Psychological aspects of communication with the patient

SAMPLE INTERVIEW ALGORITHM

(conversations)

1. Greetings. The key to communication is greeting. In a hospital situation, both basic forms of "Hello" and related forms are acceptable" Good morning!", "Good afternoon!", "Greetings! ", "I'm glad to welcome you! ".

The addressee of the greeting is our patient, so forms of familiarity, casual (“Hello!”) and ceremonial, playful, are excluded. When addressing a patient, the speech form “Hello” must contain the correct tone of communication; signs of goodwill serve as a base (key) and necessary contact.

Introduce yourself: “My name is...”.

Find out if the patient is willing to talk with you. To this end, you can ask the following questions: “Will you allow me to talk to you?” or “Can I ask you a few questions?”

4 . Ask the patient to introduce himself; familiarity is unacceptable in communication (addressing as “you”, by name, etc.). This may be considered offensive by the patient. Addressing “you” indicates great politeness. The delicately egalitarian form of addressing “You” and by first name and patronymic is justified.

Ask about his complaints, when the disturbances appeared, when the patient first noticed them. “How are you feeling?”, “What’s bothering you?”, or “What are you complaining about?”

Output adequate self-esteem the patient's worries and concerns. Find out what the significance of this symptom is, how the patient reacts to his complaints; and try to interpret his condition positively. The patient will feel relieved if the nurse allays his fears.

For example. The patient recently developed angina. The patient shows anxiety about the course of the disease. In this case, you can tell him about the facts of the risk and, depending on the specific circumstances, say: “You don’t smoke, you don’t have diabetes, your blood pressure is normal now, all these are favorable factors. You got sick recently, which means the disease has not yet advanced ".

SUCH CONVERSATIONS DO NOT JUST CALM THE PATIENT, THEY SHOW HIM A FAVORABLE PERSPECTIVE AND MOVE HIM INTO AN OPTIMISTIC WAY.

Treatment to date and its results.

Probable causes of the disease.

Time of onset of the first symptom.

Past illnesses (surgeries, injuries, allergies, wounds).

Risk factors, habits (coffee, smoking, alcohol, drugs).

Illness of family members, family history (risk factors for cancer, cardiovascular disease, diabetes, kidney disease, hypertension, mental disorders).

Working conditions, occupational hazards, habitat (unfavorable environmental conditions).

Psychological climate (social circle, temperament, character, level of development in general, lifestyle, beliefs, moral values).

Social status (role in the family, at work, financial situation).

The impact of the patient's disease and problems on him and his environment. (Does he feel anxiety or internal tension due to this):

a) for professional activities;

b) for family or partner;

c) on interpersonal relationships, on contacts;

d) for future prospects.

Appendix No. 1

You must be sure that your conversation will take place in a quiet, informal atmosphere without distractions and will not be interrupted.

Use the most reliable source of information - if not the patient himself, then his immediate family.

Use what you have previously learned about the patient's diagnoses (if you know them) to plan in advance what information to focus on and get the facts we need.

Before you begin, explain that the more you know about the patient and his family, the better care you can provide, which is why you ask him a lot of questions.

Take short notes during the interview. Carefully record the dates, number and duration of hospitalization and onset of illness.

DO NOT RELY ON YOUR MEMORY!

Don't try to write in complete sentence form.

Be calm, unhurried and empathetic. Show genuine interest and empathy.(Sensitivity encourages the patient and facilitates the expression of his feelings).

Do not become annoyed or irritated if the patient experiences memory loss. If you treat this with understanding, he may remember the necessary information later when answering the relevant question.

Use proper eye contact. Carefully observe the patient's body language.

Do not stare at the patient or your notes for too long.

Use neutral questions that encourage the patient to articulate his feelings and provide additional information.

Use leading questions sparingly to focus on unclear points. Use the patient's appropriate words to clarify information. When you say “cutting pain,” do you mean sudden, severe pain?”

Use patient-friendlyterminology . If you doubt that he understands you, ask him what he means by this or that concept.

14. To make the patient feel the appropriateness of interviewing, first of all, ask about his complaints.DON'T START WITH PERSONAL QUESTIONS!

Allow the patient to finish the sentence, even if he is too verbose. Only then ask questions. Don't jump from topic to topic. Don't repeat the question unnecessarily. If a question needs to be repeated, rephrase it for better understanding.

Be understanding of what the patient says. A simple nod, assent, or approving look will help him continue the story, especially if the patient is not dominant.

Call the patient by name. Be friendly, helpful and caring.

Don't lose your professionalism. Speak clearly, slowly and distinctly.

KNOW LISTEN !

In general, it has been observed that a balanced personWith with self-esteem comes closer to the interlocutor, while restless, nervous people they try to stay away, especially from the interlocutor of the opposite sex. When it is not known in what position the patient feels most comfortable, then you need to observe how he enters the office, the ward, how he sits, stands, holds the chair, how he moves when he thinks that they are looking at him. It is important to pay attention to the relative position and posture of the nurse and the patient.

II . Poses - reflect the state of a person and the relationship to what is happening. Almost every person has their own favorite pose orposes, therefore, it is not always easy to understand whether a given pose is an expression of a person’s state at the moment or is it just a tribute to habit. On the other hand, a frequent preference for one position or another may express a person’s susceptibility to the corresponding state. At the same time, if a person often takes the same position, as if out of habit, it is possible that he is most often thoughtful, uncommunicative, etc.

Poses can be open or closed. An open pose is determined by: turning the body and head towards the interlocutor, open palms, uncrossed position of the legs, relaxed muscles, “direct” gaze into the face.

Closed posture: Crossed legs or arms usually reflect defensive reaction and reluctance to communicate.

A quick sharp tilt or turn of the head, or gesticulation indicate that the patient wants to speak.

Sh. Movement and gestures.

Movement is understood as movement in space of the entire body, and gestures are movements. various parts body, but the movements of the head, shoulders and arms are of primary importance.

Communicative gestures (gestures that have independent meaning and do not need verbal explanations - a nod of the head in agreement, a raised finger) are made, as a rule, specifically (consciously) to convey the necessary information to the interlocutor. These are gestures: greetings, farewells, questioning, affirmative, threatening, denying, etc.

Expressive gestures and movements are often involuntary. From them you can “read” a person’s state, his attitude to what is happening. And also determine the assessment of people, events, etc., which perhaps he would like to hide. Gestures: ignorance, distrust, confusion, surprise, irony, displeasure, suffering, approval, joy, delight.

Communicative and expressive gestures may not coincide with speech and even contradict it. In this case, two options are possible:

A person deliberately wants to express with a gesture something completely different from what he forms in
speech (subtext).

A person does not say what he feels, and gestures give away, but to better understand the patient, one must be able to “read” them.

Active gestures often reflect positive emotions and is perceived as a sign of interest and friendliness. Excessive gesturing, however, can be an expression of anxiety and insecurity. Most gestures are multi-variant. For example, waving your hand can be used as a sign of desperation, attracting attention, or giving up something. Nodding your head does not always mean agreement - often they only show the speaker that he is being listened to and is ready to listen further. They seem to give permission to the speaker to continue speaking.

IV . Facial expressions. Eco coordination of facial muscle movements, reflecting states, feelings, emotions. “Facial expressions are visual language,” the main means of verbal communication, it is a signal about a person’s intentions and emotions. There are facial expressions of the upper and lower parts of the face - It is noticed that top part The faces are controlled by us more than the bottom. Therefore, if you want to learn more about a person, his condition, motives and even thoughts, look more often at the horn, the wings of the nose, and the chin. Human lips are especially expressive. Tightly compressed lips express deep thoughtfulness, curved lips indicate doubt or sarcasm. The corners of the mouth are indicators of a person’s vitality. The corners of the mouth downward are a symptom of depression, depressive state, in a joyful, cheerful state, the corners of the mouth align. The frontalis muscle is a muscle of attention or alertness; it is activated when there is danger or aggressiveness.

Fear: The eyebrows are almost straight and seem slightly raised, the eyes are widened, the lower eyelid is tense, and the upper one is slightly raised.PoWhen fearful, it is open and has a narrow elliptical shape, the lips are tense and slightly stretched. How fear is stronger, the more the corners of the mouth are pulled back.

Eyes. Eye contact.

People are sociable, open, focused on others (extroverts), look at the interlocutor more closely and longer than introverts, closed people, focused on themselves. A glance expresses our interest and helps us focus on what we are being told. If the speaker either looks into the eyes or looks away, this means that he has not finished speaking yet. If he looks straight into the eyes at the end of the phrase, he reports that he has said everything. The gaze should not be too intent (directly into the pupils). Staring can be perceived as a sign of hostility, so in argumentative situations people avoid eye contact to avoid making eye contact as an expression of hostility.

The nurse asks the patient about:- previous illnesses - the patient’s attitude towards alcohol; - nutritional characteristics; - allergic reactions to medications, food, etc.; - duration of the disease, frequency of exacerbations; - taking medications (name of the drug, dose, regularity of use, tolerability); - patient 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, and dilated veins on the anterior abdominal wall; - determination of the patient’s body weight; - body temperature measurement; pulse examination; - blood pressure measurement; - 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 medical history by filling out the “Primary Nursing Assessment Sheet”

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

Goal: to identify the patient’s difficulties and contradictions that have arisen as a result of the inability to satisfy one or more needs.

The nurse examines the patient's external reaction 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 - planning nursing care.

The nurse must be able to set specific goals and draw up a realistic 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 stage of the nursing process - implementation of the nursing care plan.

The nurse implements the planned plan of care.

1. Conducting a conversation with the patient and his relatives about the need to strictly follow a diet limiting animal fats and sufficient quantity proteins, carbohydrates and vitamins. Give a reminder about nutrition (Appendix 2). Spicy, fried and pickled foods are prohibited. If signs of renal encephalopathy appear, limit protein foods. Meals are fractional, at least 4-5 times a day. The consumption of any alcohol is strictly prohibited. Monitoring compliance with the diet - predominantly dairy-vegetable fortified foods using mainly vegetable fats.

2. Providing the patient with ward conditions. In weakened patients, bed rest is provided, which provides general care and a comfortable position in bed for the patient. Limiting physical activity. 3. 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 (medicines, their dose, rules of administration, side effects, tolerability).

6. Providing the patient with conditions for proper sleep. 7. Monitoring: - the patient’s compliance with diet, nutrition, and physical activity; - transfers to the patient; - regular use of medications; - daily diuresis; - body weight; - condition of the skin; - symptoms of bleeding (pulse and blood pressure). 8. Preparing the patient for laboratory and instrumental research methods. 9. Compliance with medical-protective and sanitary-epidemiological regimes.

10. Motivating the patient to follow the doctor’s orders and the nurse’s recommendations.

11. Monitoring the patient’s mental state.

1. Nursing examination.

2. Nursing diagnosis.

3. Planning nursing intervention.

4. R implementation of the nursing plan (nursing intervention).

5. Evaluation of the result.

The stages are sequential and interconnected.

Stage 1 SP - nursing examination.

This is the collection of information about the patient’s health status, his personality, lifestyle and the reflection of the obtained data in the nursing medical history.

Target: creation of an information base about the patient.

The foundation of nursing assessment is the doctrine of the basic vital needs of a person.

Need there is a physiological and (or) psychological deficiency of what is essential for human health and well-being.

In nursing practice, Virginia Henderson's classification of needs is used ( Model of nursing W. Henderson, 1966), which reduced all their diversity to the 14 most important and called them types of daily activities. In her work, V. Henderson used A. Maslow’s theory of the hierarchy of needs (1943). According to his theory, some needs for a person are more significant than others. This allowed A. Maslow to classify them according to hierarchical system: from physiological (lowest level) to needs for self-expression (highest level). A. Maslow depicted these levels of needs in the form of a pyramid, since it is this figure that has a broad base (base, foundation), just as the physiological needs of a person are the basis of his life (textbook p. 78):

1. Physiological needs.

2. Security.

3. Social needs (communication).

4. Self-respect and respect.

5. Self-expression.

Before you think about meeting your needs top level, it is necessary to satisfy lower-order needs.

Taking into account the realities of Russian practical healthcare, domestic researchers S.A. Mukhina and I.I. Tarnovskaya propose to provide nursing care within the framework of 10 fundamental human needs:

1. Normal breathing.

3. Physiological functions.

4. Movement.

6. Personal hygiene and change of clothes.

7. Maintaining normal body temperature.

8. Maintaining a safe environment.

9. Communication.

10. Work and rest.

Key sources of patient information

patient family members review

honey. medical staff documentation data special and honey

friends, survey literature

passers-by

Methods for collecting patient information

Thus, m/s evaluates the following groups of parameters: physiological, social, psychological, spiritual.

subjective– includes feelings, emotions, sensations (complaints) of the patient himself regarding his health;

M/s receives two types of information:

objective- data obtained as a result of observations and examinations carried out by the nurse.

Consequently, sources of information are also divided into objective and subjective.

A nursing examination is independent and cannot be replaced by a medical examination, since the task of a medical examination is to prescribe treatment, while a nursing examination is to provide motivated individualized care.

The collected data is recorded in the nursing medical history using a specific form.

A nursing medical history is a legal protocol document of the independent, professional activity of a nurse within the scope of her competence.

The purpose of the nursing medical history is to monitor the activities of the nurse, her implementation of the care plan and doctor’s recommendations, analyze the quality of nursing care and assess the professionalism of the nurse.

Stage 2 SP – nursing diagnosis

- This is the nurse's clinical judgment that describes the nature of the patient's existing or potential response to illness and his or her condition, with the desired indication probable cause such a reaction.

Purpose of nursing diagnosis: analyze the results of the examination and determine what health problem the patient and his family are facing, as well as determine the direction of nursing care.

From the point of view of a nurse, problems arise when the patient, due to certain reasons (illness, injury, age, unfavorable environment), experiences the following difficulties:

1. Cannot independently satisfy any of the needs or has difficulties in satisfying them (for example, cannot eat due to pain when swallowing, cannot move without additional support).

2. The patient satisfies his needs independently, but the way he satisfies them does not contribute to maintaining his health at an optimal level (for example, an addiction to fatty and spicy foods is fraught with diseases of the digestive system).

Problems may be :

Existing and potential.

Existing– these are the problems that are bothering the patient at the moment.

Potential– those that do not exist, but may appear over time.

By priority, problems are classified as primary, intermediate and secondary (priorities are therefore classified similarly).

Primary problems include those related to increased risk and requiring emergency assistance.

Intermediate ones do not pose a serious danger and allow for delay of nursing intervention.

Secondary problems are not directly related to the disease and its prognosis.

Based on the patient's identified problems, the nurse begins to make a diagnosis.

Distinctive features of nursing and medical diagnoses:

Medical diagnosis nursing diagnosis

1. identifies a specific disease; identifies the patient’s response

or the essence of the pathological to a disease or one's condition

process

2. reflects the medical goal - to cure the nursing goal - solving problems

patient at acute pathology patient

or bring the disease to a stage

remission in chronic

3. As a rule, correctly supplied changes periodically

the doctor's diagnosis does not change

Structure of nursing diagnosis:

Part 1 – description of the patient’s response to the disease;

Part 2 – description of the possible reason for this reaction.

For example: 1h. – eating disorders,

2h. – associated with low financial capabilities.

Classification of nursing diagnoses(according to the nature of the patient’s reaction to the disease and his condition).

Physiological (for example, the patient does not hold urine under strain). Psychological (for example, the patient is afraid of not waking up after anesthesia).

Spiritual - problems of a higher order, associated with a person’s ideas about his life values, with his religion, the search for the meaning of life and death (loneliness, guilt, fear of death, the need for holy communion).

Social - social isolation, conflict situation in the family, financial or everyday problems related to becoming disabled, changing place of residence, etc.

Thus, in W. Henderson’s model, nursing diagnosis always reflects the patient’s self-care deficit and is aimed at replacing and overcoming it. Typically, a patient is diagnosed with several health problems at the same time. The patient's problems are taken into account simultaneously: the nurse solves all the problems that she poses in order of their importance, starting with the most important and further in order. Criteria for choosing the order of importance of the patient's problems:

The main thing, in the opinion of the patient himself, is the most painful and detrimental for him or interferes with the implementation of self-care;

Problems that contribute to the worsening of the disease and a high risk of complications.

Stage 3 SP - planning nursing intervention

This is the determination of goals and the preparation of an individual nursing intervention plan separately for each patient's problem, in accordance with the order of their importance.

Target: Based on the patient’s needs, identify priority problems, develop a strategy for achieving goals (plan), and determine the criterion for their implementation.

For each priority problem, specific nursing goals are written, and for each specific goal, a specific nursing intervention must be selected.

Priority problem - specific goal - specific nursing intervention

In nursing practice, a goal is an expected specific positive result nursing intervention on a specific patient problem.

Requirements for goals:

1. The goal must correspond to the problem posed.
2. The goal should be real, achievable, diagnostic (possibility of checking achievements).
3. The goal should be formulated within the limits of nursing, not medical competence.
4. The goal should be focused on the patient, that is, it should be formulated “from the patient”, reflecting what is essential that the patient will receive as a result of nursing intervention.
5. Goals should be specific , vague general formulations should be avoided (“the patient will feel better”, “the patient will not have discomfort”, “the patient will be adapted”).
6. Goals must have specific deadlines their achievements.
7. The purpose must be clear to the patient, his family, and other health care professionals.
8. The goal should provide only a positive result:

Reduction or complete disappearance of symptoms, causing fear in a patient or anxiety in a nurse;

Improved well-being;

Expanding opportunities for self-care within the framework of fundamental needs;

Changing your attitude towards your health.

Types of goals

Short term Long term

(tactical) (strategic).

Goal structure

fulfillment criterion condition

(action) (date, time, distance) (with the help of someone or something)

For example, the patient will walk 7 meters with crutches on the eighth day.

Clearly defined nursing goals of care enable the nurse to create a plan for patient care.

Plan is a written guide that provides the sequence and phasing of nursing interventions necessary to achieve nursing goals.

Care plan standard – a basic level of nursing service that provides quality care for a specific patient problem, regardless of the specific clinical situation. Standards can be adopted both at the federal and local levels (health departments, specific medical institutions). An example of a standard of nursing practice is the OST “Protocol for the management of patients. Prevention of bedsores."

Individual care plan– a written care guide, which is a detailed listing of the m/s actions necessary to achieve the goals of care for a specific patient problem, taking into account a specific clinical situation.

Planning ensures:

· continuity of nursing care (coordinates the work of the nursing team, helps maintain communication with other specialists and services);

· reducing the risk of incompetent care (allows you to control the volume and correctness of nursing care);

· the ability to determine economic costs.

At the end of the third stage, the sister in mandatory coordinates his actions with the patient and his family.

Stage 4 SP – nursing intervention

Target: Do everything necessary to carry out the patient's plan of care.

The central point of nursing intervention is always the deficit in the patient's ability to meet his or her needs.

1. – the patient cannot perform self-care;

2. – the patient can perform self-care partially;

3. – the patient can perform self-care completely.

In this regard, nursing intervention systems are also different:

1 – fully compensating care system (paralysis, unconsciousness, prohibitions on the patient’s movement, mental disorders);

2 – partial care system (most patients in hospital);

3 – advisory and support system (outpatient services).

Types of nursing interventions:

Stage 5 SP – result evaluation

is an analysis of the patient's responses to nursing intervention.

Target: Determine the extent to which the goals have been achieved (analysis of the quality of nursing care)

The assessment process includes;

1 – determination of goal achievement;

2 – comparison with the expected result;

3 – formulation of conclusions;

4 – note in the nursing documentation of the effectiveness of the care plan.

The implementation of each item in the patient care plan leads to general case to a new patient condition, which may be:

Better than before

Without changes

Worse than before

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 a shift, while another will be assessed every hour.

If the set goals are achieved and the problem is resolved, the m/s must certify this by signing the relevant goal and setting a date.

The main criteria for the effectiveness of nursing care include:

Progress towards achieving goals;

Patient's positive response to the intervention;

The obtained result corresponds to the expected one.

If the goal is not achieved, it is necessary:

Identify the cause - search for the mistake made.

Change the goal itself, make it more realistic.

Reconsider deadlines.

Make necessary adjustments to the nursing care plan

PROBLEM QUESTIONS:

1. How do you understand the meaning of the definition: nursing is a way to meet the vital needs of a person? Give examples of the connection between a patient’s problems that require the intervention of a nurse and a violation of meeting the needs of his body in a situation of illness.
2. Why is the nursing process called a circular and cyclical process?
3. Describe the differences between traditional and modern approach to the organization of nursing care for the patient.
4. Is the goal of nursing intervention correctly formulated: the nurse will provide good sleep patient? Give your version.
5. Why is the nursing history called a mirror, reflecting the qualifications and level of thinking of the nurse?

Topic: “NOMACHICAL INFECTION.

INFECTION SAFETY. INFECTION CONTROL"

Plan:

· Concept of nosocomial infections.

· Main factors contributing to the prevalence of nosocomial infections.

· Causative agents of nosocomial infections.

· Sources of nosocomial infections.

· Infectious process. Chain of infectious process.

· The concept of the sanitary-epidemiological regime and its role in the prevention of nosocomial infections.

· Orders of the Ministry of Health regulating the sanitary and epidemiological regime in health care facilities.

· Concept of decontamination. Hand treatment levels.

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 a patient, it is necessary to familiarize yourself with his medical documentation, if possible, remember the 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.

It is necessary to use elements of 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 nurse improve your skills and abilities.

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 the facial expression, state of consciousness, position of the patient, condition of the skin and visible mucous membranes, condition musculoskeletal system, 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 activities include monitoring all changes in the patient’s health status, timely identifying these changes, assessing them, 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 sleep, the patient is unconscious, reflexes are not preserved, he can be brought out of this state with a loud voice, but he soon falls back into sleep.
• 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 abdomen). 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 at high temperature - shiny eyes, facial flushing;
• ? 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. Severe condition - passive position in bed, active actions are difficult to perform, consciousness may be altered, facial expression may be altered. 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 the nursing documentation they must 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 the patient cannot perform independent actions of care and is cared for by medical personnel 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 should rely on the doctor's diagnosis, know the patient's lifestyle, risk factors that worsen his condition, be aware of his emotional and psychological state and other aspects that help her to decide 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 a patient’s problem with subsequent documentation is very important; it requires professional knowledge and the ability to find a connection between signs of abnormalities in the patient’s health status and the reasons that cause them. This skill also depends on the intellectual abilities of the 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, a nursing textbook (Carlson Kraft and McCurry) proposed the following definition in response to changing views on nursing:

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, insufficient 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, the cause of its occurrence and the direction of the nurse's further actions. 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 current problems, for example 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) the patient’s medical diagnosis or doctor’s diagnosis. A medical diagnosis determines a disease based on a special assessment of physical signs, medical history, and diagnostic tests. The task of medical diagnosis is to prescribe treatment for the patient;
• 3) human treatment that may have unwanted side effects 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 and decide which professional healthcare worker 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 entire illness. Nursing diagnosis may change daily or even throughout the day as the body's responses change;
• ? a medical diagnosis involves treatment within the scope of medical practice, and a nursing diagnosis involves nursing interventions within the scope of her competence and practice;
• ? A medical diagnosis, as a rule, is associated with the pathophysiological changes that have occurred in the body; 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 localization 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 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 personality of the medical worker providing assistance, towards the quality of the manipulations performed, loneliness, etc.);
• 14) changes in hygienic needs (lack of hygienic knowledge, skills, problems with medical care, 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:

• ? a person’s movements, his facial expressions, voice timbre and rate of speech, vocabulary provide a lot of varied information about the patient;
• ? 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, 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, with pronounced emotional states the 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 the arterial pressure. 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.

Each goal necessarily 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 over a 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.

A nursing intervention plan is a written guide that details specific nursing actions, including 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) creating comfortable conditions for life in order to meet the basic needs of the patient;
• 4) rendering psychological support and help;
• 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 reaction to treatment, provide first aid, carry out personal hygiene measures, 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 all stages of the nursing process and making necessary adjustments.

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 continually collects and critically analyzes information and draws conclusions about the patient's reactions to care, the feasibility of implementing the plan of care, and the presence of new problems that need attention. Thus, we can highlight the main aspects of the assessment:

• ? goal achievement;
• ? patient's response 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 has a need for nursing care, it is necessary to reassess his health status in order to establish the reasons for the deterioration of the condition or the moment when no improvement in the patient's condition has 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.

Nursing process for respiratory diseases. Respiratory diseases account for more than 60% of childhood morbidity.
Nursing process acute pneumonia
Information about the disease. Pneumonia is acute inflammation lung tissue.
Etiology: infectious - pneumococci, staphylococci, viruses, mycoplasma. Most often there is a mixed viral-bacterial etiology. In 60-80% of cases of “domestic” pneumonia, the causative agent is pneumococcus.
Predisposing factors: perinatal pathology, congenital heart defects, hypovitaminosis; chronic foci of infection of the ENT organs, repeated acute respiratory viral infections, recurrent bronchitis, active and passive smoking. In the development of pneumonia, the state of reactivity of the child’s body is of great importance.
The infection enters by airborne droplets, and then spreads bronchogenically through the respiratory tract, lingering in the bronchioles and alveoli, causing local inflammation, infiltration and filling of the alveoli with exudate. Main mechanisms pathological process are the development of intoxication (exposure to bacteria and their toxins) and respiratory failure, since as a result of impaired external respiration, the lungs are not able to ensure normal gas exchange.
Clinical manifestations, the duration of the course, the nature of complications depend on the type of pneumonia and the age of the child.
Types of acute pneumonia:
Focal - most common in young children; inflammation involves areas of lung tissue measuring at least 1 cm.
Ogagovo-confluent - observed in children of different ages; inflammation affects areas of lung tissue in several segments or throughout the entire lobe of the lung.
Segmental - occurs in children of different ages; inflammation involves one or more segments of the lungs, sometimes involving the pleura.
Lobar (lobar) - pneumococcal, observed in older children; inflammation takes over an entire lobe of the lungs. The course of this pneumonia is severe with severe symptoms of intoxication and respiratory failure.
Interstitial - a rare form of pneumonia caused by mycoplasma or pneumocystis; inflammation affects the interalveolar connective (interstitial) tissue of the lungs; characterized by rapid development of respiratory failure.
Children of preschool and school age with uncomplicated pneumonia can be treated on an outpatient basis in a “hospital at home” setting.
Indications for hospitalization: children in the first six months of life; children, regardless of age, with severe and complicated course of the disease; in the absence of effect from treatment on an outpatient basis; in the absence of conditions for treatment at home; children from socially disadvantaged families.
Principles of treatment: bed rest for the entire febrile period; nutritious meals according to age; drug therapy: antibiotics, mucolytic drugs, infusion therapy. Physiotherapeutic treatment. Exercise therapy, massage.

Stages of the nursing process for acute pneumonia:

Stage 1. Collection of information

— Subjective examination methods:
Typical complaints: hyperthermia with chills in lobar pneumonia; loss of appetite, weakness, malaise; dry or wet cough, the appearance of rusty sputum with lobar pneumonia; pain in chest, shortness of breath.
History (amnesis) of the disease: the onset is acute with an increase in body temperature.
— Objective examination methods:
Examination: the child’s health is disturbed, lethargic, fever; pale skin, cyanosis of the nasolabial triangle; groaning breathing, shortness of breath (40 per minute in children over 2 years old, 60 per minute in children under 2 years old), participation of auxiliary muscles in the act of breathing with retraction of the intercostal spaces, tachycardia. With percussion - shortening of the pulmonary sound; on auscultation - weakened breathing, the presence of moist rales.
Results of diagnostic methods (from outpatient card or Medical history): complete blood count: neutrophilic leukocytosis and increased ESR; X-ray of the lungs - the presence of focal, segmental, polysegmental infiltration, or occupying part or the entire lobe.

Stage 2. Identifying the problems of a sick child

A patient with pneumonia has impaired needs: to maintain body temperature, maintain general condition, breathe, eat, sleep, rest, communicate.
Existing problems caused by intoxication: increased body temperature, malaise, weakness, headache, loss of appetite.
Existing problems. caused by the development of respiratory failure: shortness of breath, participation of auxiliary muscles in the act of breathing, tachycardia.
Potential problems: acute respiratory failure; acute cardiovascular failure: prolonged and chronic course.

3-4 stages. Planning and implementation of patient care in a hospital

The purpose of care: to promote recovery and prevent the development of complications.
Nursing care plan for a patient in a hospital-at-home treatment setting. The nurse provides:
Organizing bed rest for the entire period of fever, until your well-being and general condition improve.
Organization of nutrition: dairy-vegetable diet. If there is no appetite, reduce the daily amount of food by 1/2 or 1/3, replenishing drinking plenty of fluids liquids.
In accordance with the doctor’s prescriptions: antibacterial therapy, expectorants and mucus thinners, symptomatic therapy, home physiotherapy.
Independent interventions:
- active visiting of a sick child until complete recovery:
— monitoring the child’s response to treatment;
- dynamic observation and assessment of the child’s general condition: position in bed, well-being, color of the skin and mucous membranes, appetite, presence and nature of cough, body temperature, frequency, depth and rhythm of breathing;
- training the child and parents in “coughing techniques”, vibration massage for sputum evacuation, creating a drainage position, conducting home physiotherapy - mustard plasters, mustard wraps, inhalations;
— consulting the child and his parents regarding his health;
— conducting health education conversations about the disease and prevention of complications.
Nursing process in acute pneumonia
Care plan
1. Ensure organization and control over compliance with the medical and protective regime
Implementation of care:
Independent interventions: Conduct a conversation with the patient and/or parents about the disease and prevention of complications; explain to the patient and/or parents the need to adhere to the regimen; raise the head of the bed: perform postural drainage 2-3 times a day; recommend that the mother of an infant pick him up more often and change his position in the crib.
Motivation:
Protection of the central nervous system from excessive external stimuli. Creating a gentle regime, ensuring maximum comfort conditions. Easier breathing. Evacuation of sputum
2. Provide organization and control over nutrition
Implementation of care:
Independent interventions: Conducting a conversation with the patient/parents about nutrition; Recommend parents to bring foods high in carbohydrates, fruits, vegetables; Do not force-feed the child; if the child refuses food, make up for the missing daily volume by drinking fluids
Motivation:
Satisfying physiological needs
3. Organization of leisure time
Implementation of care:
Independent Intervention: Encourage parents to bring their child’s favorite books, games, etc.
Motivation:
Creating conditions for compliance with the regime
4. Creating comfortable conditions in the ward
Implementation of care:
Independent interventions: Monitor wet cleaning and regular ventilation; regularity of changing bed linen; maintaining silence in the room
Motivation:
Improved breathing. Satisfaction physiological needs in a dream
5. Assisting with hygiene measures and eating
Implementation of care:
Independent interventions: Conduct a conversation about the need for hygiene; Recommend parents to bring toothpaste, a comb, and a clean change of underwear
Motivation:
Ensuring sanitary and hygienic measures. Need to be clean
6. Follow doctor's orders
Implementation of care:
Dependent interventions: Administration of antibiotics, ensuring medication intake: conducting infusion therapy Independent interventions: Explain to the patient and/or parents about the need to administer antibiotics and take other medications; conduct a conversation with the patient and/or parents about possible side effects of therapy; accompany to physiotherapeutic procedures
Motivation:
Etiotropic treatment. Prevention of complications. Early detection side effects. Detoxification
7. Provide dynamic monitoring of the patient’s response to treatment
Implementation of care:
Independent intervention: Questioning about well-being, complaints, recording the nature of the cough; measuring body temperature in the morning and evening; BH. Heart rate. If your general condition worsens, immediately inform your doctor
Motivation:
Monitoring the effectiveness of treatment and care. Early detection and prevention of complications.

Stage 5. Assessing the effectiveness of care

At proper organization After nursing care, the child’s recovery occurs, the patient is discharged under the supervision of a local pediatrician. The patient and his parents should be aware of the peculiarities of the regime, nutrition, physical activity that the child must follow after the disease, about the need dispensary observation and strict adherence to all recommendations.

5 steps of the nursing process for pneumonia

In her work, the nurse is guided by the regulations on the medical institution, department, job description, this provision, legislative and regulatory documents of the Russian Federation on issues of public health, as well as orders and instructions of higher authorities and officials.

The main task of a nurse is to provide qualified nursing care to the patient and his family, including disease prevention, care and emergency pre-hospital medical care during illness and rehabilitation.

Nursing is an integral part of the healing process. Timely recognition of diseases, correct treatment and good care ensure the patient's recovery. In her work, the nurse is obliged to follow the orders and instructions of the doctors under whose guidance she works.

In her daily work, a nurse has the following responsibilities:

upon admission of a patient to the department, checks the quality of sanitary treatment of the patient, shows the admitted patient his room and bed, and, if necessary, participates in transferring him from a stretcher to a bed or accompanies him to the bed;

introduces admitted patients to the internal regulations and department regulations, monitors their compliance;

monitors the sanitary condition in the wards, the regularity of their ventilation (at 7-8 o'clock, 14-15 o'clock, 21 - 22 o'clock) and air temperature (not lower than 18-200C);

monitors patients’ compliance with personal hygiene rules and the regularity of changing bed and underwear;

measures the body temperature of patients and enters the measurement data into a temperature sheet; calculates pulse and respiration rates, daily amounts of urine and sputum; performs anthropometry of the patient;

participates in the doctor’s rounds, informs him about the condition of the patients and their compliance with the regimen;

records the doctor’s instructions on prescription sheets and strictly follows them (dispenses medications, performs injections, administers cupping, mustard plasters, enemas, leeches, etc.);

collects biological material for sending to the laboratory (urine, sputum, feces, etc.);

prepares patients for various studies and transports them to diagnostic rooms;

monitors compliance with medical nutrition of patients, monitors products;

monitors the proper maintenance of medical equipment and furniture;

maintains post medical documentation: draws up a portion requirement, makes a selection of medical prescriptions from the medical history, draws up a requirement for medications, draws up a summary of

the condition of the patients, fills out the sheet for registering the bed capacity, the register for registering medications of list A and B, the register for appointments and transfer of duty;

in emergency cases, provides pre-hospital emergency care;

carries out sanitary educational work among patients.

The nursing process consists of five main stages.

1. Nursing examination includes the collection of information about the patient’s health status, which can be subjective and objective.

The subjective method involves the study of physiological, psychological, social data about the patient; relevant environmental data. The source of information is a conversation with the patient, conducting an examination, studying previously recorded medical documentation data, talking with a doctor, and the patient’s relatives.

The objective method involves conducting a physical examination of the patient, which includes the assessment and description of various parameters ( appearance, state of consciousness, position in bed, degree of dependence on external factors, color and moisture of the skin and mucous membranes, the presence of edema). They also measure the patient's height, determine his body weight, measure temperature, count and estimate the number of respiratory movements, pulse, measure and estimate blood pressure.

Conducting an examination involves compiling documentation of the information received and creating a nursing medical history, which is a legal protocol - a document of the independent professional activity of the nurse.

2. Identifying the patient's problems. Among the patient's problems, existing and potential ones are distinguished. TO existing problems These include those problems that are currently troubling the patient.

Potential ones are those that do not yet exist, but may arise over time. The nurse's task to identify as much as possible the factors that contribute to or cause the development of these problems also reveals the patient's strengths, which he can counteract the problems.

The patient is characterized by the presence of several problems, then the nurse’s task is to determine a system of priorities - primary and secondary. Primary priorities are those that can have the first impact harmful influence on the patient.

The second stage ends with the establishment of a medical diagnosis. Medical diagnosis focuses on recognizing pathological conditions, while nursing diagnosis is based on describing patients' reactions to health problems.

3. Determining the goals of nursing care and planning nursing activities. The nursing care plan includes operational and tactical goals that are aimed at achieving certain long-term or short-term results.

When formulating goals, it is necessary to take into account actions (execution), criteria (date, time, distance, expected result) and conditions (with the help of what and by whom). Once nursing goals and objectives have been established, the nurse's actions are directed toward developing a written nursing manual that details the nurse's specific nursing actions and records them in the nursing record.

4. Implementation of planned actions. This stage includes measures that the nurse takes to prevent diseases, examine, treat, and rehabilitate patients.

Dependent nursing intervention is carried out on the basis of physician orders and under his supervision.

Independent nursing intervention involves actions carried out by the nurse on his own initiative, guided by his own considerations, without direct demands from the doctor. For example, teaching the patient hygiene skills, organizing the patient’s leisure time, etc.

Interdependent nursing intervention involves the joint activities of the nurse with the doctor, as well as with other specialists.

In all types of interactions, the sister's responsibility is exceptionally great.

5. Assessing the effectiveness of nursing care. This stage is based on the study of the dynamic reactions of patients to the nurse's interventions. The sources and criteria for assessing nursing care are the following factors: assessment of the patient's response to nursing interventions; assessing the degree to which nursing care goals have been achieved; assessing the effectiveness of nursing care on the patient’s condition; active search and assessment of new patient problems.

Thus, we have found out that pneumonia, or pneumonia, is an acute inflammatory process that involves all elements of the lung tissue. And most importantly, the smallest particles of the lung are affected - the alveoli (bubbles), which are responsible for gas exchange. Mostly bacterial pneumonias are caused by pneumo-, staphylo-, streptococci and other bacteria, but during an influenza epidemic, influenza pneumonia also develops. This is a serious test not only for patients, but also for medical personnel, the successful outcome of which is determined by the timely diagnosis of the onset of the disease, adequate treatment and attentive care, and care for the patient. Therefore, correct, professional and timely organized nursing process is necessary to prevent complications and largely determines a successful prognosis.

Nursing process for pneumonia

The role of nursing staff in medical activities is very important. Despite the level of education received by doctors, not a single doctor can cope with his work without a nurse. Contrary to the apparent simplicity and simplicity, working in such a position implies not only blind obedience to the doctor’s instructions, but also your own medical analysis. Each pathology, or at least each group of pathologies, involves multi-stage work, starting with a conversation with the patient and nursing diagnosis and ending with communication with the doctor and suggestions for adjusting treatment. This article will discuss the topic of the nursing process for pneumonia: why it is needed, what stages it includes and how it should be carried out correctly.

Nursing process for pneumonia

Pneumonia - what is it?

Pneumonia is an inflammatory process provoked by various infectious agents, characterized by the presence of certain pathogenetic - alveolar exudation, clinical and radiological signs.

Main symptoms of pneumonia

Etiology, i.e. the cause of the development of the disease, is an attack by infectious agents. In its own way biological nature these can be different microorganisms:

• bacteria(pneumococcus, Haemophilus influenzae, mycoplasma, Escherichia coli, streptococcus, staphylococcus, etc.);
• viral particles(herpes simplex virus, adenovirus);
• fungi.

It's important to remember that pneumonia is not contagious disease . Some microorganisms are absolutely present in the body healthy person. The main pathogenetic link is infectious inflammation against the background of reduced immunity. When in the respiratory tract, for one reason or another, local immunity, local defense, suffers, microbes actively multiply and can cause disease.

Microorganisms enter Airways in various ways - with blood or lymph flow, with air. In the alveoli (these are “bubbles”, the final sections of the lungs in which gas exchange occurs), an inflammatory process develops, which, penetrating through the thin alveolar membrane, spreads to other pulmonary sections. Due to the “work” of microbes in the alveoli, an inflammatory fluid (exudate) is formed, which prevents full gas exchange from occurring.

The disease affects the alveoli

At-risk groups

The following categories of citizens are most susceptible to pneumonia:

• children;
• aged people;
• people infected with HIV (this category has special types of pneumonia caused by bacteria that are absolutely harmless to healthy people);
• people with a history of chronic bronchitis;
• patients with chronic heart failure;
• patients with severe chronic diseases (oncology, autoimmune pathology);
• weakened people forced to remain in bed for a long period of time;
• postoperative patients;
• long-term smokers suffering from chronic obstructive pulmonary disease (COPD).

Elderly people are at risk

Clinical manifestations

Exist different shapes of this disease, but the main symptoms are similar for everyone

Cough. Usually it is unproductive, barking, tormenting a person, paroxysmal, and does not stop even at night. On the second or third day of illness, a small amount of viscous, thick, yellow-green sputum, sometimes streaked with blood, begins to come out.

Cough with pneumonia

Chest pain is another symptom

Note! The more severe the pneumonia, the more symptoms there will be. Tachycardia (increased heart rate), confusion, decreased blood pressure, and signs of failure of other organs may occur.

The main diagnostic sign is the presence radiological symptoms, without them the diagnosis cannot be considered verified even with “ full set» clinical manifestations.

Classification of pneumonia

Pneumonia is a disease that has many different classifications. The disease is divided according to the type of pathogen, localization (unilateral, bilateral) and distribution (lobar, segmental, total, hilar), form (according to pathoanatomical and pathophysiological principles).

The most important classification– this is community-acquired and nosocomial pneumonia, hospital-acquired. The difference is that the first variant of the disease develops no later than 48 hours after a person’s admission to a hospital or outside a medical facility. In the second case, the disease manifests symptoms after 48 hours of a person’s stay in the hospital. The second type of pneumonia is much more dangerous and more complex than the first. Why?

Table. How does community-acquired pneumonia differ from hospital-acquired pneumonia?

This pathology is also classified according to severity - mild, moderate and severe. This criterion determines whether the patient requires hospitalization. Thus, a mild degree of the disease does not imply hospitalization, it is acceptable ambulatory treatment. However, in this situation there are special cases regarding:

• children;
• pensioners;
• multimorbid patients (with a large number of diseases);
• people who are unable to care for themselves and for whom there is no one to care for them;
• family members with small children;
• socially unadapted citizens who do not have the opportunity to purchase the necessary medications for treatment.

A multimorbid patient at the present stage is a very common phenomenon

Note! All of them are placed in a hospital and mild form pneumonia.

People with signs of severe disease must be hospitalized:

• saturation less than 95;
• blood pressure below 100/60 mmHg;
• heart rate above 100;
• respiratory rate is more than 20;
• no response to therapy (temperature does not decrease) within 3 days.

Goals of nursing care

Close monitoring of a patient with pneumonia by a nurse is necessary, both in the case of community-acquired pneumonia and in nosocomial pneumonia (especially). Why?

1. Doctors are not in the department around the clock; in addition, they have a lot of “paper” work and cannot constantly monitor the patient’s condition even in the intensive care unit.
2. A patient with pneumonia may experience a deterioration in their condition at any time - increased shortness of breath, a drop in blood pressure.
3. With this disease, especially in its nosocomial form, in the absence of proper action on the part of the patient and medical personnel, serious complications can develop, including respiratory failure and death.
4. Most drugs, especially in the first days of treatment, are administered intravenously.

Intravenous administration of drugs

In this regard, the goals of the nursing process are as follows:

• monitor the patient’s vital signs (saturation level, blood pressure and heart rate, respiratory rate, temperature, general condition);
• administer all necessary medications prescribed by the doctor;
• perform a nursing examination, identify the patient’s problems (pain, poor sleep, antibiotic-associated diarrhea, etc.) and report them to the doctor;
• prevent the development of complications;
• consistent and A complex approach to the nursing process. It is worth considering each stage separately.

Features of the nursing process

Stages of the nursing process

From the moment a patient is admitted to a hospital until he is discharged from there, the nurse becomes the primary caregiver. Her work begins with the patient's first appearance in the hospital.

Stage I. Acquaintance

At this stage, the nurse should introduce herself to the patient, if he is conscious, explain how the department is arranged, where the toilet, sanitary room and dining room are located, the resident's room, the nursing staff room, and how to urgently call for help. Show the patient his room.

At the initial stage, the patient and sister get to know each other

After the patient is placed in the ward, it is necessary to bring him an informed consent to medical intervention for signature, explaining what it includes, what it is needed for and what obligations it imposes on the patient and medical staff. The nurse must then complete all required paperwork at the station.

After the “paper” procedures, a conversation with the patient is carried out. Complaints, anamnesis (history) of the disease and life are collected. Important points:

• whether the patient has concomitant chronic diseases, especially tuberculosis, hepatitis B and C, syphilis, HIV infection, tuberculosis (even treated);
• whether the patient is taking any therapy;
• does he have his own pills for blood pressure/problems with stool/diabetes, etc.;
• whether the person is allergic to medications or other irritants - food, household allergens;
• whether the patient has bad habits;
• whether the patient has ever had blood transfused;
• does the person have problems with sleep, with bowel movements, how does he tolerate pain, is he afraid of the sight of blood;
• whether the patient has a headache, weakness, photosensitivity or photophobia.

Collecting information about the patient's condition

Note! During the conversation, the nurse must capture not only subjective details (what the patient says), but also objective aspects - whether he is easy to contact, how he feels about his disease, whether he suffers from it not only physically, but also morally.

At the end of the conversation, the nurse should make a nursing diagnosis. It includes the underlying disease, the presence of concomitant ones, as well as a listing of the prevailing syndromes. For example, it may sound like this: lower lobe pneumonia on the right, complicated by pleurisy; headache syndrome. High nervous excitability, tendency to hypochondria. Allergy to penicillin antibiotics.

Skin allergies

Stage II. Drawing up a problem correction plan

Based on the information collected, the nurse should prepare a plan for correcting the identified problems. For example, with severe shortness of breath, it is necessary to establish oxygen inhalation and check blood saturation every hour. For headaches, you should choose an anesthetic drug. In the presence of significant intoxication with high temperature it is necessary to infuse a large amount of saline with low doses of diuretics. After drawing up the plan, it must be approved by the attending physician.

Stage III. Implementation of a plan. Observation

Once the proposed actions have been agreed upon with the doctor, you must begin to implement them. It is important to carefully follow all doctor’s instructions regarding medications, carry out intravenous and intramuscular injections of antibiotics, bring pills and monitor the patient’s reaction to the medications. In the event of side effects, intolerance to the drug, or the development of an allergic reaction to it, the nurse must immediately notify the attending physician.

In addition, the responsibilities of nursing staff include constant monitoring of vital signs and notifying the doctor about their changes.

Monitoring the patient's condition

Another area of ​​responsibility is the conditions of detention. The following must be monitored.

1. Air temperature in the room. Optimal conditions are 23-24°C. It shouldn't be too hot and stuffy to pathogenic microorganisms did not accumulate and did not multiply in the air, but cold weather should not be allowed, since this could cause a deterioration in the patient’s condition and the development of other infectious diseases.
2. Cleanliness in the room. Of course, hygiene measures in the department are the responsibility of the nurses. However, nurses must monitor the situation in the room, the absence of dust on window sills, beds and bedside tables, and the cleanliness of the floors. It is important to control the contents of refrigerators and cabinets.
3. Patient position. A patient with pneumonia must be turned over if his condition is serious, or ensure that he turns over on his own, since prolonged congestion in the lungs makes it more difficult to discharge sputum, which, in turn, provokes an even greater proliferation of microorganisms.
4. Medical "attributes". If you have a permanent venous access (catheter), it is important to monitor its cleanliness and change it on time. The nasal tube for oxygen supply and inhalers (nebulizer masks) must also be clean.

The patient should remember the need for physical activity

Stage IV. Monitoring treatment results

Of course, the best indicator of treatment success is an improvement in the patient’s condition. Correctly collected complaints, both active and passive, will help the doctor adjust therapy in time, if necessary, and adequately assess progress. The following trend is observed: patients are more willing to report their problems to a nurse than to a doctor, seeing in the latter a cold and distant specialist, and in the former - a friend, assistant, sometimes an interlocutor and a sympathetic person (the amount of time the staff spends with the patient is affected). Therefore, patients often report constipation or diarrhea (which often occurs in connection with taking antibiotics), persistent shortness of breath, weakness or chest pain only to the nurse.

Patients trust the nurse more than the attending physician

The assistance and care of medical personnel for a patient with pneumonia significantly accelerates recovery, allows not only to carry out therapeutic and therapeutic measures in in full, but correct the condition by additional methods – breathing exercises, appropriate conditions of stay and nutrition for the patient. In addition, the presence of proper care improves the mood of patients (especially the elderly and lonely), instills a “fighting spirit”, and patients with pneumonia recover faster.