The concept of the nursing process. Main stages of the nursing process

Nursing process - a method of scientifically based and practical implementation by a nurse of her duties in providing care to a patient.

Target nursing process– ensuring an acceptable quality of life for a patient with illness, that is, ensuring the maximum possible physical, mental and spiritual comfort for the patient in his state.

Implications of the nursing process for nursing practice:

Identifies the patient's specific care needs and ensures patient participation in care;

Contributes to the selection of care priorities from a range of existing needs and predicts expected care outcomes;

Determines the nurse's action plan and strategy to meet the patient's needs;

With its help, the effectiveness of the work carried out by the sister and her professionalism are assessed. And most importantly, the nursing process guarantees the quality of care nursing care.

Nursing process consists of five stages, each of which is an essential stage in solving a priority problem and is closely related to the other four:

Nursing assessment efficiency

nursing process survey

Interpretation implementation

nursing plan data received

and formulation

priority problem

(nursing diagnostics) planning

nursing care

Conclusion: The nursing process is a sequential change of actions (stages) performed by the nurse in relation to the patient with the aim of preventing, reducing and minimizing the problems and difficulties associated with his health.

First stage - nursing examination.

This is the ongoing process of collecting and recording information about the patient's health status and the degree to which the patient's needs are being met.

Target stage - creation information base about the patient.

Types of nursing information

Subjective Objective

Information sources

Methods for obtaining information.

The nurse should collect information and evaluate the following parameter groups :

1. Condition of the main functional systems body.

2. Emotional and intellectual background, range of adaptation to stress.

3. The ability to perform self-care.

4. Sociological data.

5. Information about environment("risk factors").

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

Nursing history - legal protocol is an independent document, professional activity nurses within the scope of her competence.

Data documentation makes it possible to:

· identify gaps in patient care,

· reveals full information about the work done,

· clearly shows the dynamics patient's condition,

· ensures continuity and systematic approach In the organisation nursing care,

· Helps to exercise self- and mutual control.

WITH educational sample Nursing medical history can be found in the appendix.

Conclusion: Thus, at stage 1, the nurse receives two types of information:

subjective– includes feelings, emotions, sensations (complaints) of the patient himself

regarding your health;

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

Second phase - nursing diagnosis.

This is the formation of present or possible future deviations from a comfortable state and the formulation of a priority problem / nursing diagnosis /.

Target stage - identifying the problems that arise in the patient, identifying the factors causing the development of these problems, identifying those qualities of the patient that can help prevent or resolve his problems.

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

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).

Patient problems.

Present / existing / Potential

* Physiological

* Social

* Psychological

* Spiritual

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).

TO primary include problems associated with increased risk and requiring emergency assistance.

Intermediate do not pose a serious danger and can be delayed nursing intervention.

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

Priority issue/nursing diagnosis/ is a clinical judgment of a nurse that describes the nature of the patient’s existing or potential response to an illness or condition with a desired indication probable cause this reaction.

In 1987, at the first international conference in Calgary, much attention was paid to the problems of nursing diagnostics.

In 1991, nursing diagnosis was included in the US standards of nursing practice.

In 1992, the Tenth US Conference of Nursing approved a list of 109 nursing diagnoses.

Soon the concept of “nursing diagnosis” becomes international.

Currently in the Russian Federation the concept of “nursing diagnosis” does not have official recognition.

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

Distinctive features nursing and medical diagnoses:

Structure of nursing diagnosis:

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

Part 2 – description possible reason such a reaction.

For example: 1h. – eating disorders,

2h. – associated with low financial capabilities.

Conclusion: problems arise for the patient when there are difficulties in meeting needs. The nurse does not consider the disease itself, but the patient's response to the disease and changes in health status.

Third stage - nursing care planning.

E then defining goals and drawing up 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.

During planning, the nurse sets priorities, defines goals, expected outcomes, and formulates a plan of nursing care.

Priority is what weighs most heavily on the patient. present moment, is the main thing for him now or can worsen his health and well-being.

Criteria for choosing the priority/significance/ 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 high risk development of complications.

In nursing practice target - is the expected specific result of nursing intervention for a specific patient problem.

When setting goals, the nurse considers the following:

· must be real, achievable, diagnostic (verifiable),

· have specific deadlines for achieving them:

Short-term – no more than 1 week,

Long-term – several weeks, months, years,

· be within nursing competence, not medical competence,

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,

· formulated on behalf of the patient/family/, i.e. be understandable to the patient.

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.

Plan is a written care guide that contains a detailed listing of all the actions of the nurse, in agreement with the patient, necessary to achieve the goals.

Plan:

· Coordinates the work of the nursing team,

· ensures continuity of nursing care,

· Helps maintain communication with other health professionals,

· reduces the risk of incompetent or careless care,

· involves the patient and his family in providing care.

When developing a plan of care, the nurse may use the appropriate standard of nursing intervention as a guide.

Standard (standard care plan) is a list of activities that provide quality patient care for this problem, this is

minimum mandatory level of quality of nursing care.

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 nursing guide, which is a detailed listing of the nurse’s actions necessary to achieve nursing goals for a specific patient problem, taking into account a specific clinical situation.

Conclusion: In the third step, the nurse writes down specific nursing goals for each priority problem and selects a specific nursing intervention for each specific goal.

Lecture

Topic: “Nursing process, degrees of nursing process”

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

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

SP has 3 characteristics:

1) he must be patient-specific;

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

3) all steps must be interconnected.

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

Nursing process It has 5 stages:

1) examination of the patient;

2) making a nursing diagnosis or identifying patient problems;

4) intervention or implementation of plans;

5) assessment.

Stage 1 - Examination of the patient.

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

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

1) Physiological needs

· subjective

· objective

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

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

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

· subjective

· objective

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

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

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

Stage 2 – Identifying the patient’s problem.

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

There are several problems.

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

Stage 3 – Planning.

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

Priorities are classified:

1) primary– which, if not eliminated, may have harmful influence patient (all types emergency care, heat And heart attack, respiratory arrest, bleeding);

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

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

Planning there is short-term and long-term.

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

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

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

Stage 4 – Intervention or implementation of the plan.

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

Intervention There are dependent, interdependent, independent.

· Dependent is the fulfillment of medical prescriptions.

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

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

Stage 5 – Assessment.

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

· Improvement

· Recovery

· Without changes

· Tightening

· Deterioration

Death of the patient (fatal outcome)

The goal may be partially achieved or not achieved.

2. SD reforms. In practice (analysis)

2) VSO appeared in more than 22 Russian universities.

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

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

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

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

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

The essence of the reform:

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

2) VZO more than 20 universities in Russia.

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

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

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

In our Republic, college education has existed since 1993.

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

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

Lecture

Topic: “Nursing process: concepts and terms”

1. Introduction.

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

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

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

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

The nursing process consists of 5 stages:

Stage 1 – nursing examination

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

Stage 3 – setting goals and planning care

Stage 4 – Implementation of the care plan

Stage 5 – assessment and correction of care if necessary.

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

1. breathe normally

3. physiological functions

4. movement

5. sleep and rest

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

7. maintain body temperature within normal limits

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

9. maintain communication with other people

10. work and rest.

2. Stage 1 – examination of the patient

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

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

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

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

3. Stage 2 – nursing diagnosis

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

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

Stages of the nursing process

The nursing process includes 5 sequential stages:

Stage I- nursing examination (patient examination).

Stage II- nursing diagnosis: identifying patient problems and making nursing diagnoses.

Stage III- planning necessary assistance to the patient, aimed at satisfying the identified needs and problems.

Stage IV- implementation of the nursing intervention plan.

Stage V- assessment of results (final assessment of nursing care).

All stages of the process are interconnected and together form a continuous cycle of thinking and action.

Nursing examination- this is the identification of violations of the patient's needs. It consists of collecting information about the state of his health, the patient’s personality, lifestyle and reflecting the obtained data in the nursing process chart (nursing medical history). How skillfully the nurse can position the patient for the necessary conversation, the information received will be more complete. Patient assessment is an ongoing, systematic process that requires observational and communication skills. Purpose of the assessment - identification of a person’s specific nursing care needs.

Nursing examination is independent and cannot be replaced by a doctor, since they are faced with different tasks. The doctor conducts an examination, puts medical diagnosis, identifies the causes of dysfunction of organs and systems in order to further treatment. Nurse's task - justification of motivation for individual care.

There are five sources of patient information:

1. The patient himself.

2. The patient’s non-medical environment: relatives, acquaintances, colleagues, roommates.

3. Medical environment: doctors, nurses, ambulance crews medical care.

4. Medical documentation: outpatient card, medical history, examination notes, tests.

5. Special medical literature: care guides, standards nursing activities, atlas of manipulation techniques, list of nursing diagnoses, journal “Nursing”.

There are two types of information about the patient: subjective and objective, as well as additional examination

Subjective data- These are the patient’s own feelings regarding health problems. Typically, this information is collected through a survey. The nurse conducts a survey during the interview.

Goals of the conversation:

· establishing a trusting relationship with the patient;

· familiarize the patient with the treatment;

· development of an adequate attitude of the patient to his states of anxiety and anxiety;

· determining the patient's expectations from the medical care system;

· obtaining information that requires in-depth study.

First you need introduce yourself to the patient, state your name, position, and state the purpose of the conversation. Then find out from the patient how to contact him. This will help him feel comfortable. During the conversation, personal data is collected - full name, age, gender, place of residence, occupation, and the reasons for contacting a medical institution are also indicated.

When examining a patient, you need to find out:

· the state of his health, taking into account each of the 14 fundamental needs for W. Henderson ;

· what the patient considers normal for himself in connection with each specified need;

· what kind of help the patient needs to meet each need;

· how and to what extent the current state of health prevents him from performing self-care;

· what potential difficulties or problems can be foreseen in connection with changes in his health; previous illnesses and problems.

At subjective examination it turns out:

· data from medical history (Anamnesis morbi): the onset of the disease, its course, what it is associated with, what the patient did on his own, where he went for help, what kind of help was provided;

· data from life history (Anamnesis vitae): previous illnesses, infectious diseases, tuberculosis, venereal diseases, injuries, operations, healing procedures, blood transfusion, the patient's response to past treatment and the quality of nursing care provided;

risk factors: smoking, alcohol, obesity, stressful situations, etc.;

allergy history: for medicinal substances, food, household chemical substances and etc.;

· what basic needs the patient can satisfy himself, and to satisfy which ones he needs help;

· are there any visual, hearing, memory, or sleep impairments;

· who or what is the support for the patient;

· how he himself assesses his condition, how he feels about the procedures.

Objective data The nurse receives information about the patient’s condition as a result of examining the patient, monitoring him and examining him.

At objective examination The nursing staff examines the patient according to a specific plan in compliance with a number of necessary rules. The patient is examined in diffuse daylight or bright artificial lighting. The light source should be on the side: this will highlight the contours more prominently various parts bodies, rashes, scars, traces of wounds, etc.

Acquaintance With the objective condition of the patient begins with examination, then moving on to feeling (palpation), tapping (percussion), and listening (auscultation). It is recommended that all examination data be recorded in the nursing documentation.

Evaluation appearance and patient behavior should be based on observations made throughout the collection process medical history and examinations. Evaluate general state patient (satisfactory, moderate, severe); state of consciousness (clear, sopor, stupor, coma); behavior (adequate, inappropriate). They also determine: position in bed (active, passive, forced), physique, height, weight, body temperature.

During examination conditions of the skin and mucous membranes evaluate: color (cyanosis, pallor, hyperemia, jaundice), humidity, temperature, elasticity and turgor, pathological elements, hair, nails, oral cavity and pharynx, etc. When examining the tongue, the presence of plaque and bad breath should be assessed.

Survey musculoskeletal system you can start with the question of the presence of pain in the joints, their localization, distribution, symmetry, irradiation, character and intensity. It is necessary to determine what increases or decreases the pain, how physical activity affects it. During examination, the presence of deformities of the skeleton, joints, and limited mobility is determined. If mobility in a joint is limited, it is necessary to find out which movements are impaired and to what extent: can the patient walk, stand, sit, bend, stand up, dress, wash freely. Limited mobility leads to limited self-care. Such patients are at risk of developing pressure ulcers and infection and therefore require increased attention by the nursing staff.

During examination respiratory system it is necessary to pay attention to changes in voice, frequency, depth, rhythm and type of breathing, chest excursion, assess the nature of shortness of breath, transfer physical activity; hemoptysis, pain in chest, shortness of breath.

During examination of cardio-vascular system pulse and arterial pressure. Symmetry, rhythm, frequency, filling, tension, and pulse deficit are assessed. When complaining of pain in the heart area, the nature, localization, irradiation, duration of pain, and how it is relieved are determined. Characteristic sign cardiovascular pathology- swelling. You should also pay attention to dizziness, fainting. Such patient problems can cause falls and injuries.

When assessing the condition gastrointestinal tract attention should be paid to dysphagia, heartburn, loss of appetite, nausea, vomiting, belching and other dyspeptic disorders. From the conversation and examination, you can get information about bleeding from the rectum, constipation, diarrhea, abdominal pain, flatulence, jaundice associated with pathology of the liver and gallbladder. It is necessary to evaluate appetite, the nature and frequency of stool, and the color of stool.

When assessing urinary system pay attention to the nature and frequency of urination, urine color, transparency, urinary incontinence. Urinary and fecal incontinence are risk factors for the development of pressure ulcers, psychological and social problem patient.

When assessing endocrine system nursing staff need to pay attention to the nature of hair growth, the spread of subcutaneous fat, visible increase thyroid gland. Often, endocrine system disorders lead to psychological discomfort associated with changes in appearance.

During examination nervous system find out whether the patient had loss of consciousness or convulsions. When determining the nature of sleep, it is necessary to pay attention to its duration and the nature of falling asleep. Sleep may be superficial and restless. It is important to know whether the patient uses sleeping pills and which ones.

Presence of tremor, gait disturbances suggest a risk of injury and are aimed at solving the problem of patient safety during a hospital stay.

During examinationreproductive system among women find out the age of onset of the first menses, regularity, duration, frequency, amount of discharge, date of last menstruation, premenstrual syndrome, the impact of menstruation on general well-being. From what age has he been sexually active, how many pregnancies, births, miscarriages, abortions, methods of birth control. For middle-aged women, you should find out whether and when their menstruation stopped, and whether the cessation was accompanied by any symptoms.

After completing the survey you should ask the patient if he has any questions. At the end, it is necessary to explain to the patient what awaits him next, introduce him to the daily routine, employees, premises, roommates, and hand over a memo about his rights and responsibilities.

Upon completion of the examination nursing staff draw conclusions and record them in nursing documentation. Subsequently, every day, throughout the patient’s stay in the hospital, it is recommended to display the dynamics of the patient’s condition in an observation diary.

Laboratory and instrumental studies are classified as additional methods.

The patient himself is the source subjective, so objective information.

Monitoring the patient's condition. The nurse's job involves monitoring all changes in the patient's condition, timely allocation their assessment, informing the doctor about these changes, providing assistance.

After the assessment state of the patient’s health, the nurse must formulate the patient’s problems or conduct a nursing diagnosis using the nursing practice classifier.

The end result of the first stage The nursing process is to document the information received and create a database about the patient. The collected data is recorded in the nursing medical record. Nursing history - legal document independent activity of a nurse within her competence. Purpose of nursing history- monitoring the nurse’s implementation of the care plan and doctor’s recommendations, analyzing the quality of nursing care and assessing the professionalism of the nurse.

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 the 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 like 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 satisfying higher-order needs, you need 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. Maintenance normal temperature bodies.

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

- It 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, preferably indicating the likely cause of that response.

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).

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 problems associated with 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 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:

The goal must correspond to the problem posed.
The goal should be real, achievable, diagnostic (possibility of checking achievements).
The goal should be formulated within the limits of nursing, not medical competence.
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.
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”).
Goals must have specific deadlines their achievements.
The goal must be clear to the patient, his family, and others medical workers.
The goal should provide only a positive result:

Reduction or complete disappearance of symptoms that cause fear in the patient or anxiety in the 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 system of assistance (paralysis, unconsciousness, prohibitions for the patient to move, 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;

Reply positive reaction patient for 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:

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.
Why is the nursing process called a circular and cyclical process?
Describe the differences between traditional and modern approach to the organization of nursing care for the patient.
Is the goal of nursing intervention correctly formulated: the nurse will provide good sleep patient? Give your version.
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 goal of the nursing process is to prevent, alleviate, reduce or minimize the problems that the patient has.

The nursing process consists of 5 stages:

1. nursing examination (collection of information about the patient);
2. nursing diagnosis (identification of needs);
3. setting goals and planning care;
4. implementation of the care plan;
5. assessment and correction of care if necessary.

All stages are necessarily recorded in the documentation for the implementation of the nursing process.

Stage I - nursing examination. The nurse must clearly understand the uniqueness of each of her patients in order to implement such a requirement for professional care, as the individuality of the nursing care provided. Taking into account the realities of Russian practical healthcare, it is proposed to provide nursing care within the framework of 10 fundamental human needs. To do this, she questions the patient, performs a physical examination of his organs and systems, studies his lifestyle, identifies risk factors for this disease, gets acquainted with the medical history, talks with doctors and relatives, studies medical and special literature on disease prevention and patient care. Having carefully analyzed all the collected information, the nurse proceeds to stage II - nursing diagnosis.

Nursing diagnosis always reflects the patient's self-care deficit and is aimed at accommodating and overcoming it. Nursing diagnosis may change daily and even throughout the day as the body's responses to illness change. Nursing diagnoses may be physiological, psychological, spiritual, social, present or potential. At the end of the second stage, the nurse identifies priority problems, that is, those problems whose solution is most important at the moment.

At stage III, the nurse forms goals and draws up an individual plan for nursing interventions. When developing a plan of care, the nurse can be guided by the standards of nursing practice, which list the activities that ensure quality nursing care in this area. nursing problem. At the end of the third stage, the nurse must coordinate her actions with the patient and his family and record them in the nursing history.

Stage IV - implementation of nursing interventions. The sister does not necessarily do everything herself; she entrusts some of the work to other people - the younger medical personnel, relatives, the patient himself. However, she takes responsibility for the quality of the activities performed. There are 3 types of nursing interventions: 1. Dependent intervention - performed under the supervision of a doctor and as prescribed by a doctor; 2. Independent intervention - the nurse’s action at her own discretion, that is, helping the patient with self-care, monitoring the patient, advice on organizing leisure time, etc. 3. Interdependent intervention - collaboration with doctors and other specialists.

The task of stage V is to determine the effectiveness of nursing intervention and correct it if necessary. The assessment is carried out by the nurse continuously, individually. If the problem is resolved, the nurse should provide reasonable assurance in the nursing record. If the goal was not achieved, the reasons for the failure should be determined and the necessary adjustments should be made to the nursing care plan. The nursing process is applicable in any area of nursing practice, including preventive work.