Methods of nursing examination of the patient. The first stage of the nursing process is examining the patient. Components of the nursing process are all except

Lecture

Topic: “Nursing process, degrees of nursing process”

Nursing process- this is a modern, scientifically sound and cost-effective method of organizing 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– these are the social conditions of patients, everyday life, working conditions, environmental data, finances, the presence of 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, can have a detrimental effect on the patient (all types of emergency care, high fever and heart attack, respiratory arrest, bleeding);

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

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

Planning there is short-term and long-term.

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

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

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

Stage 4 – Intervention or implementation of the plan.

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

Intervention There are dependent, interdependent, independent.

· Dependent is the fulfillment of medical prescriptions.

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

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

Stage 5 – Assessment.

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

· Improvement

· Recovery

· Without changes

· Tightening

· Deterioration

Death of the patient (fatal outcome)

The goal may be partially achieved or not achieved.

2. SD reforms. In practice (analysis)

2) VSO appeared in more than 22 Russian universities.

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

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

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

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

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

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 a public organization of 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. Mukhina and Tarnovskaya adapted 10 needs to Russian conditions:

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 are classified as additional examination methods.

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

3. Stage 2 – nursing diagnosis

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

Identify the causes that cause the development of these problems, as well as the patient’s strengths that would help prevent or resolve them.

Nursing process- This is a method of scientifically based and practical implementation by a nurse of his duties in providing care to patients.

This method involves the patient and the nurse as interactants. At the core is the patient as an individual requiring an individual approach.

Purpose of the joint venture– maintaining and restoring the patient’s independence in meeting basic human needs through skilled nursing care. The goal of the nursing process is achieved by solving the following tasks:

• creation of a patient information database;
• identifying the patient's health care needs;
• designation of priorities in medical care;
• developing a plan of care and providing care according to the patient's needs;
• determining the effectiveness of the patient care process and achieving the goal of care for that patient.

Importance of the nursing process

The significance of implementing the nursing process is as follows:

• a systematic and individual approach to nursing care is provided;
• active participation of the patient and his family in planning and providing care becomes necessary;
• the possibility of widespread use of professional activity standards is created;
• efficient use of time and resources is carried out;
• demonstrates the level of professional competence, responsibility and reliability of the medical service and medical care;
• ensures the safety of medical care;
• Most importantly, the nursing process ensures quality of care that can be monitored.

The nursing process brings a new understanding of the role of the nurse in practical healthcare, requiring from her not only good technical training, but also the ability to be creative in caring for patients, the ability to work with the patient as an individual, and not as an object of “manipulation technology.” Constant presence and contact with the patient makes the nurse the main link between the patient and the outside world. The biggest winner in this process is the patient. The outcome of the disease often depends on the relationship established between the nurse and the patient and on their mutual understanding.

Stages of the nursing process

1. Nursing examination - assessment of the patient's condition.
2. Nursing diagnostics – interpretation of data obtained during examination and identification of patient’s health problems.
3. Setting goals and planning for upcoming care work.
4. Implementation of the drawn up plan - implementation of nursing interventions.
5. Evaluation of results and effectiveness of nursing care.

The first stage is a nursing examination.

The purpose of this stage is to collect information about the patient’s health status to identify his impaired needs, existing and potential problems, in order to ensure the patient’s quality of life. Medical diagnostics aims to make a diagnosis, identify the cause and mechanism of development of the disease.

Sources of information can be:

• the patient himself is the best source;
• family members, accompanying persons, roommates;
• doctors, nurses, ambulance crew members, paramedics;
• medical documentation (examination data, extracts from inpatient or outpatient records);
• special medical literature (care guides, standards of nursing procedures, professional journals).

There are subjective and objective nursing examinations.

Subjective examination– information obtained from the words of the patient or other person. Subjective information - the patient’s ideas about his health. The completeness of the information depends on the nurse’s ability to persuade the interlocutor to communicate.

Objective examination– direct examination and additional methods – data from laboratory and instrumental studies (for example, blood and urine tests, X-ray studies) and special measurements (for example: measuring height and body weight).

The second stage is nursing diagnosis.

Purpose of the stage:

• identifying the patient's problems;
• identification of factors contributing to or causing the development of these problems;
• identifying the patient's strengths that would help prevent or resolve problems.

Patient problem is the patient’s response to an illness or health condition. In addition, this is a deliberate conclusion based on analysis of information. In some countries the problem is called a "nursing diagnosis". In our country, this formulation is not entirely justified, since the diagnosis is carried out by the doctor.

The problem is different from the doctor's diagnosis:

Types of nursing diagnoses (problems)

According to the nature of the patient’s reaction to the disease and his condition:

1. Physiological– reactions to the disease caused by changes in the functions of organs and systems (the body reacts to inflammatory changes in the lungs by disrupting the functions of the respiratory organs: shortness of breath, cough...).
2. Psychological– reactions that appeared in response to painful changes in the internal organs (fear, tearfulness, emotional vulnerability).
3. Social– associated with a violation of the satisfaction of social needs due to illness (incomplete family, financial insolvency, loss of ability to work).
4. Spiritual– reactions of the body that affect the spiritual sphere (loss of meaning in life, unwillingness to take care of oneself, turning to religion, loneliness).
Intermediate - do not require emergency measures, not life-threatening (decreased appetite, weakness)
5. Secondary– are not directly related to this disease (intestinal dysfunction in a patient with bronchitis).

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 a 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 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. 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

- 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).

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 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 with acute pathology of the 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 associated with 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 the expected specific positive result of nursing intervention for 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 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 care 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 nurse must coordinate her 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 care (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 generally leads to a new condition for the patient, which can 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 approaches to organizing nursing care for a patient.
4. Is the goal of nursing intervention correctly formulated: will the nurse ensure that the patient gets adequate sleep? 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.

Each stage of the nursing process is closely interconnected with the others and serves its main task - helping the patient solve his health problems.
To organize and provide quality care for a patient, nursing staff need to collect information about him from all possible sources. It can be obtained from the patient himself, his family members, witnesses of the incident, the nurse herself, and her colleagues. Based on the information collected, problems are identified and identified, a plan is drawn up, and planned actions are implemented. The success of treatment largely depends on the quality of the information received.
Nursing examination differs from medical examination. The goal of a doctor’s activity is to make a diagnosis, identify the causes, mechanism of development of the disease, etc., and the goal of the nursing staff is to ensure the quality of life of a sick person. To do this, first of all, it is necessary to identify the patient’s problems related to the current or potential state of his health.
Information about the patient must be complete and unambiguous. Collecting incomplete, ambiguous information leads to an incorrect assessment of the patient's needs for nursing care, and, as a result, to ineffective care and treatment. The reasons for collecting incomplete and ambiguous information about the patient may be:
inexperience and disorganization of nursing staff;
inability of nursing staff to collect specific information regarding a specific area;
the nurse’s tendency to jump to hasty conclusions, etc.

Sources of information when examining a patient

Nursing staff obtain patient information from five main sources.
1) from the patient himself;
2) relatives, acquaintances, roommates, random people, witnesses of the incident;
3) doctors, nurses, members of the ambulance team, nurses;
4) from medical documentation: inpatient cards, outpatient cards, extracts from medical histories of previous hospitalizations, examination data, etc.;
5) from special medical literature: care guides, standards of nursing procedures, professional journals, textbooks, etc.
Based on the data obtained, one can judge the patient’s health status, risk factors, characteristics of the disease, and the need to provide nursing care to the patient.
Patient- the main source of subjective and objective information about yourself. In cases where he is incapacitated, comatose, or an infant or child, the main source of data may be his relatives. Sometimes they alone know about the characteristics of the patient’s condition before and during the illness, about the medications he takes, allergic reactions, attacks, etc. However, do not think that this information will be exhaustive. Other data may be obtained from other sources, perhaps even contradicting the data of the main ones. For example, a spouse may report family tension, depression, or addiction to alcohol, which the patient denies. Information received from family members can affect the speed and quality of care. If there is a discrepancy in the data, you should try to obtain additional information from other persons.
The patient’s medical environment is a source of objective information based on the patient’s behavior, his response to treatment, obtained during diagnostic procedures, and communication with visitors. Each member of the health care team is a potential source of information and can report and verify data obtained from other sources.
The main medical documentation required by nursing staff is an inpatient or outpatient card. Before starting to interview the patient, nursing staff familiarize themselves with such a card in detail. In case of re-hospitalization, previous medical histories are of interest; they are requested from the archive if necessary. This is a source of valuable data regarding the characteristics of the course of the disease, the volume and quality of nursing care provided, psychological adaptation, the patient’s reactions to hospitalization, negative consequences associated with the patient’s previous hospital stay or seeking medical help. In the process of getting the nursing staff acquainted with the patient's medical history, hypotheses may arise about the possible causes of his problems (work in hazardous work, family history, family troubles).
The necessary information can also be gleaned from documentation from the place of study, work, service, or from medical institutions where the patient is or has been observed.
The patient's or their guardian's permission must be given before requesting documentation or interviewing a third party. Any information received is confidential and is considered part of the patient's official medical record.
At the final stage of collecting information, nursing staff can use special medical literature on patient care.
There are two types of patient information: subjective and objective.
Subjective information- This is information about the patient’s feelings regarding health problems. For example, complaints of pain are subjective information. The patient can report the frequency of pain, its characteristics, duration, location, intensity. Subjective data include patient reports of anxiety, physical discomfort, fear, complaints of insomnia, poor appetite, lack of communication, etc.
Objective information- results of measurements or observations. Examples of objective information include indicators of measuring body temperature, pulse, blood pressure, identification of rashes on the body, etc. Objective information is collected in accordance with existing norms and standards (for example, on the Celsius scale when measuring body temperature).

Subjective data obtained from the patient and his non-medical environment confirm the physiological changes expressed by objective indicators. For example, confirmation of the patient’s description of pain (subjective information) - physiological changes expressed in high blood pressure, tachycardia, heavy sweating, forced position (objective information).
To fully collect information about the past and present state of health (life history and medical history), nursing staff conducts a conversation with the patient, studies the medical history, and gets acquainted with the data of laboratory and instrumental studies.

Survey as the main method of collecting subjective information about the patient

A nursing examination usually follows a medical examination. The first step in a nursing examination of a patient is the collection of subjective information using a nursing interview (collection of primary information about objective and/or subjective facts from the words of the interviewee).
When conducting a survey, it is necessary to use specific communication skills in order to focus the patient’s attention on his state of health, to help him understand the changes that are occurring or will occur in his lifestyle. A friendly attitude towards the patient will allow him to cope with problems such as mistrust of medical personnel, aggression and agitation, hearing loss, and speech impairment.
Objectives of the survey:
establishing a trusting relationship with the patient;
familiarizing the patient with the course of treatment;
developing an adequate patient attitude towards states of anxiety and anxiety;
clarifying the patient's expectations from the medical care system;
obtaining key information that requires in-depth study.
At the beginning of the interview, you must 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.
Most patients, when seeking medical help and especially when in a hospital, experience anxiety and restlessness. They feel defenseless, afraid of what awaits them, afraid of what they may find out, and therefore they hope for participation and care, and feel joy from the attention they receive. The patient must be reassured, encouraged, and given the necessary explanations and advice.
During the survey, not only the nursing staff, but also the patient receives the information he needs. If contact is established, the patient will be able to ask questions of interest. To answer them correctly, it is necessary to try to understand the patient's feelings. Particular caution must be exercised when patients ask for advice on a personal matter. The opportunity to talk about it with medical personnel is usually more important than the answer itself.
If the interview is successful, there is an opportunity to establish trust with the patient, involve him in formulating goals and drawing up a nursing care plan, and resolve questions regarding the need for consultation and patient education.
The patient should be observed during the interview. His behavior with family members and the health care environment will help to understand whether the data obtained through observation are consistent with those identified during the survey. For example, if the patient states that he is not worried but appears anxious and irritable, observation will provide the opportunity to obtain the necessary additional information.
By listening to the patient and skillfully having a conversation with him, you can find out what worries him and what problems he has, what, in his opinion, was the cause of his condition, how this condition developed, and what he thinks about the possible outcome of the disease.
Everything that can be learned by collecting an anamnesis helps to formalize the history of nursing observation of the patient and highlight those problems that should be given special attention.

Patient nursing chart

In accordance with the State educational standard, the study of a patient's nursing history (NIH) is included in the training program for nursing personnel in all schools and colleges of the Russian Federation. In accordance with the chosen nursing model, each educational institution develops its own patient observation chart or nursing medical history. At the end of this section (Chapter 16) there is a nursing care card for the patient, which is filled out in medical schools and colleges in the Moscow region.
The NIB must indicate the date of the patient interview, and in the event of a rapid change of circumstances, the time.
The presentation of information received from the patient is usually preceded by certain information of an introductory nature.
Personal data (age, gender, place of residence, occupation) will allow you not only to establish who the patient is, but also to get an approximate idea of ​​what kind of person he is and what health problems he may have.
The method of entering a medical facility or seeking help will help understand the patient's possible motives. Patients,
those who sought help on their own initiative differ from those who received referrals.
Source of information. The ISS must indicate from whom the information about the patient was received. This could be himself, his relatives, friends, members of the medical team, or police officers. The necessary information can also be gleaned from the patient’s documentation.
The reliability of the source is indicated if necessary.

Subjective examination

Main complaints. The main part of the NIB begins with this section. It is better to write down the words of the patient himself: “My stomach hurts, I feel very bad.” Sometimes patients do not make obvious complaints, but state the purpose of hospitalization: “I was admitted simply for examination.”
History of the present illness. Here it is necessary to clearly indicate, in chronological order, those health problems that forced the patient to seek medical help. Information can come from the patient or his environment. Nursing staff must organize information. It is necessary to find out when the disease began; the circumstances under which it arose, its manifestations and any independent treatment undertaken by the patient (taking medications, enema, heating pad, mustard plasters, etc.). If the illness is accompanied by pain, find out the following details:
location;
irradiation (where does it give off?);
character (what does she resemble?);
intensity (how strong is it?);
time of occurrence (when does it start, how long does it last, and how often does it appear?);
the circumstances under which it occurs (environmental factors, emotional reactions or other circumstances);
factors that aggravate or alleviate pain (physical or emotional stress, hypothermia, taking medications (what exactly, in what quantities), etc.);
accompanying manifestations (shortness of breath, arterial hypertension, ischuria, dizziness, tachycardia, dilated pupils, forced posture, facial expressions, etc.).
In a similar way, you can detail other manifestations of the patient’s disease or condition (nausea and vomiting, stool retention, diarrhea, anxiety, etc.).
In the same section they write down what the patient himself thinks about his disease, what made him see a doctor, how the disease affected his life and activity.
In the life history section, all previous illnesses, injuries, medical procedures, dates of previous hospitalizations, the patient’s response to past treatment and the quality of nursing care provided are indicated.
The patient’s condition at the time of examination, living conditions, habits, and attitude towards health make it possible to identify the strengths and weaknesses that must be taken into account when planning nursing care.
Family history makes it possible to assess the patient’s risk of developing certain diseases that are hereditary in nature. If a family pathology is detected, relatives may be involved in examination and treatment.
A psychological history helps to get to know the patient as a person, to assess his likely reactions to the disease, his mechanisms of adaptation to the situation, the patient’s strengths, and his anxiety.

Objective examination

The main task of an objective examination of the patient’s organs and systems is to identify those important health problems that have not yet been mentioned in the conversation with the patient. Often the patient’s painful condition is caused by a disruption in the normal functioning of an organ or system as a whole. It is better to start finding out the state of a particular system with general questions: “How is your hearing?”, “Do you see well?”, “How does your intestines work?” This will allow the patient to concentrate on the subject of the conversation.
The nursing process is not a mandatory component of nursing activities, therefore it is recommended that the patient be examined according to a specific plan in compliance with the necessary rules recommended during a medical examination.
An objective assessment of the patient’s condition begins with a general examination, then moves on to palpation (feeling), percussion (tapping), and auscultation (listening). Proficient in percussion, palpation and auscultation - professional
the task of a doctor and a nurse with higher education. The inspection data is entered into the NIB.

Assessment of the patient's general condition

The patient's appearance and behavior should be assessed using observations made during the history and examination. Does the patient hear the nurse's voice well? Does he move easily? What's his gait like? What is he doing at the time of the meeting, sitting or lying? What's on his bedside table: a journal, postcards, a prayer book, a vomit container, or nothing at all? Assumptions made on the basis of such simple observations can help in choosing nursing care tactics.
It is necessary to pay attention to how the patient is dressed. Is he neat? Is there a smell coming from it? You should pay attention to the patient’s speech, monitor his facial expression, behavior, emotions, reactions to the environment, and find out his state of consciousness.
The patient's state of consciousness. When assessing him, you need to find out how adequately he perceives the environment, how he reacts to medical personnel, whether he understands the questions that are asked to him, how quickly he answers, whether he is inclined to lose the thread of the conversation, fall silent or fall asleep.
If the patient does not answer questions, you can resort to the following techniques:
address him loudly;
shake him slightly, as is done when waking up a sleeping person.
If the patient still does not respond, it should be determined whether he is in a state of stupor or coma. Impairment of consciousness can be short-term or long-term.
To assess the degree of impairment of consciousness and coma in children over 4 years of age1 and adults, the Glasgow Coma Scale (GCS)2 (GCS) is widely used. It consists of three assessment tests: eye opening (E), speech (V) and motor (M) reactions. After each test, a certain number of points are awarded, and then the total is calculated.

Table. Glasgow Coma Scale

Interpretation of the results obtained:
15 points - clear consciousness;
13-14 points - stunning;
9-12 points - stupor;
6-8 points - moderate coma;
4-5 points - terminal coma;
3 points - death of the bark.
Patient position. It depends on the general condition. There are three types of patient position: active, passive and forced.
The patient, who is in an active position, easily changes it: sits down, stands up, moves around; serves himself. In a passive position, the patient is inactive, cannot independently turn around, raise his head, arm, or change body position. This situation is observed when the patient is unconscious or in a state of hemiplegia, as well as in cases of extreme weakness. The patient takes a forced position to alleviate his condition. For example, when there is pain in the stomach, he tightens his knees, when he is short of breath, he sits with his legs down, holding his hands on a chair, couch, or bed. Pain is indicated by suffering on the face and increased sweating.
Patient's height and weight. They find out what his usual body weight is and whether it has changed recently. The patient is weighed, normal body weight is calculated, his height is measured, and it is determined whether he has weakness, fatigue, or fever.
In patients with impaired nutritional needs and excretion of waste products from the body, body weight and height data are used as the main indicators in treatment. A person’s height and body weight largely depend on his diet and nature of nutrition, heredity, past diseases, socio-economic status, place of residence and even time of birth.
Nursing staff often have to determine the height and weight of patients, especially in pediatric practice or during preventive examinations. The scale-stadiometer device produced by the medical industry allows you to carry out these measurements with great time savings.
There is no consensus on the issue of normal body weight (proper weight) of an adult. With the simplest method of calculation, a person’s normal body weight should be equal to his height in centimeters minus 100. So, with a person’s height of 170 cm, the normal body weight is 70 kg. When calculating ideal body weight, a person’s height, gender, age and body type are taken into account. To determine your ideal body weight, you must use special tables.
To measure a person’s body weight and height, it is necessary to follow a certain algorithm.

Table. Basic human body types

Table. Ideal body weight of a person, taking into account his physique and height, kg*

Table. Ideal body weight for various age groups taking into account human height, kg
Note. In table Data from men and women not included in risk groups were used. For people with an increased risk of developing cardiovascular pathology and diabetes mellitus, normal body weight values ​​should be lower than these.

Algorithm for measuring patient height

Purpose: assessment of physical development.
Indications: examination upon admission to hospital or preventive examination.
Equipment: stadiometer, pen, medical history.
Problems: The patient cannot stand. 1st stage. Preparation for the procedure
1. Collect information about the patient. Introduce yourself kindly to the patient. Find out how to contact him. Explain the upcoming procedure and obtain consent. Assess the patient's ability to participate in the procedure.
Rationale:
ensuring the patient’s psychological preparation for the upcoming procedure;
respect for patient rights.
2. Place oilcloth or disposable padding under your feet. Invite the patient to take off his shoes, relax, and for women with high hairstyles, let their hair down.
Rationale:
ensuring the prevention of nosocomial infections;
obtaining reliable indicators. 2nd stage. Execution of the procedure.
3. Invite the patient to stand on the stadiometer platform with his back to the stand with the scale so that he touches it with three points (heels, buttocks and interscapular space).
Rationale:
4. Stand to the right or left of the patient. Rationale:
ensuring a safe hospital environment.
5. Slightly tilt the patient’s head so that the upper edge of the external auditory canal and the lower edge of the orbit are on the same line, parallel to the floor.
Rationale:
ensuring reliable indicators.
6. Lower the tablet onto the patient’s head. Fix the tablet, ask the patient to lower his head, then help him get off the stadiometer. Determine the indicators by counting along the bottom edge.
Rationale:
providing conditions for obtaining results;
ensuring a protective regime. 8. Report the obtained data to the patient. Rationale:
ensuring patient rights. 3rd stage. End of the procedure
8. Remove the foot wipe from the stadiometer platform and throw it into the trash container.
Rationale:
prevention of nosocomial infections.
9. Record the received data in the medical history. Rationale:
ensuring continuity of nursing care. Note. If the patient cannot stand, the measurement is taken while he is in a sitting position. The patient should be offered a chair. The fixation points will be the sacrum and interscapular space. Measure your height while sitting. Record the results.

Algorithm for weighing and determining the patient’s body weight

Purpose: To evaluate physical development or the effectiveness of treatment and nursing care.
Indications: preventive examination, diseases of the cardiovascular, respiratory, digestive, urinary or endocrine systems.
Equipment: medical scales, pen, medical history.
Problems: patient's serious condition.
1st stage. Preparing for the procedure.
1. Collect information about the patient. Politely introduce yourself to him. Ask how to contact him. Explain the procedure and the rules for carrying it out (on an empty stomach, in the same clothes, without shoes; after emptying the bladder and, if possible, bowel movements). Obtain patient consent. Assess the possibility of his participation in the procedure.
Rationale:
establishing contact with the patient;
respect for patient rights.
2. Prepare the scales: align; adjust; close the shutter. Place oilcloth or paper on the scale platform.
Rationale:
ensuring reliable results;
ensuring infectious safety. 2nd stage. Execution of the procedure.
3. Ask the patient to take off his outer clothing, take off his shoes and carefully stand on the center of the scale platform. Open the shutter. Move the weights on the scales to the left until the level of the rocker matches the reference level.
Rationale:
ensuring reliable indicators.
4. Close the shutter. Rationale:
ensuring the safety of the scales.
5. Help the patient get off the weight platform. Rationale:
ensuring a protective regime.
6. Write down the received data (you must remember that a large weight is used to fix tens of kilograms, and a small one - for kilograms and grams).
Rationale:
determining whether the patient’s actual body weight corresponds to the ideal one using the body mass index (BMI) - the Quetelet index.
Note. BMI is equal to a person's actual body weight divided by a person's height squared. With BMI values ​​in the range of 18-19.9, the actual body weight is less than normal; with BMI values ​​in the range of 20-24.9, the actual body weight is equal to the ideal; A BMI of 25-29.9 indicates the pre-obesity stage, and a BMI >30 means that the patient is obese.
7. Provide data to the patient. Rationale:
ensuring patient rights. 3rd stage. End of the procedure.
8. Remove the napkin from the site and throw it into the trash container. Wash the hands.
Rationale:
prevention of nosocomial infections.
9. Enter the obtained indicators into the NIB. Rationale:
ensuring continuity of nursing care.
Note. In the hemodialysis department, patients are weighed in bed using special scales.

Assessment of the condition of the skin and visible mucous membranes

When examining, palpating (if necessary) the skin and visible mucous membranes, you should pay attention to the following characteristics.
Coloring of the skin and mucous membranes. Examination reveals pigmentation or its absence, hyperemia or pallor, cyanosis or yellowness of the skin and mucous membranes. Before the examination, you should ask the patient if he has noticed any changes in his skin.
There are several characteristic changes in the color of the skin and mucous membranes.
1. Hyperemia (redness). It can be temporary, caused by taking a hot bath, alcohol, fever, severe anxiety, and permanent, associated with arterial hypertension, working in the wind or in a hot room.
2. Pale. Temporary pallor can be caused by excitement or hypothermia. Severe pallor of the skin is characteristic of blood loss, fainting, and collapse. Hyperemia and pallor are best seen on the nail plates, lips and mucous membranes, especially on the mucous membrane of the oral cavity and conjunctiva.
3. Cyanosis (cyanosis). It can be general and local, central and peripheral. General characteristic of cardiovascular failure. Local, for example, for thrombophlebitis. Central cyanosis is more pronounced on the lips and mucous membrane of the mouth and tongue. However, lips take on a bluish tint even at low ambient temperatures. Peripheral cyanosis of the nails, hands, and feet can also be caused by excitement or low room temperature.
4. Icterus (yellowness) of the sclera indicates possible liver pathology or increased hemolysis. Yellowness may appear on the lips, hard palate, under the tongue and on the skin. Jaundice of the palms, face and soles may be due to the high content of carotene in the patient's food.
Moisture and oiliness of the skin. The skin may be dry, moist or oily. Skin moisture and the condition of subcutaneous tissue are assessed by palpation. Dry skin is characteristic of hypothyroidism.
Skin temperature. By touching the patient's skin with the back of your fingers, you can judge its temperature. In addition to assessing your overall temperature, you should check the temperature of any reddened area of ​​the skin. During the inflammatory process, a local increase in temperature is noted.
Elasticity and turgor (firmness). It is necessary to determine whether the skin folds easily (elasticity) and whether it quickly straightens out after this (turgor). A frequently used method for assessing skin elasticity is palpation.
A decrease in the elasticity and firmness of the skin, its tension is observed with edema and scleroderma. Dry and inelastic skin may indicate tumor processes and dehydration. It must be taken into account that with age, the elasticity of a person’s skin decreases and wrinkles appear.
Pathological elements of the skin. When pathological elements are detected, it is necessary to indicate their characteristics, localization and distribution on the body, the nature of the location, the specific type and time of their occurrence (for example, with a rash). The result of itchy skin can be scratching, which leads to a risk of infection for the patient. When examining, it is necessary to pay special attention to them, since the cause of their occurrence can be not only dry skin, allergic reactions, diabetes mellitus or other pathology, but also scabies mites.
Hairline. During the examination, it is necessary to pay attention to the nature of hair growth and the amount of hair of the patient. People often worry about hair loss or excess hair growth. Their feelings must be taken into account when planning nursing care. A thorough examination can identify individuals with pediculosis (lice infestation).
The discovery of lice and scabies is not a reason to refuse hospitalization. With timely isolation and appropriate sanitary treatment of patients, their stay within the walls of the health care facility is safe for others.
Nails. It is necessary to examine and feel the fingernails and toenails. Thickening, discoloration of the nail plates, and their fragility can be caused by a fungal infection.
The condition of hair and nails, the degree of their grooming, and the use of cosmetics will help to understand the patient’s personal characteristics, his mood, and lifestyle. For example, overgrown nails with half-erased varnish, long-undyed hair may indicate a patient’s loss of interest in his appearance. An unkempt appearance is typical for a patient with depression or dementia, but appearance should be judged based on what is likely to be normal for the individual patient.

Assessment of the state of the senses

Organs of vision. Assessing the condition of the patient’s visual organs can begin with the questions: “How is your vision?”, “Are your eyes bothering you?” If the patient notices a deterioration in vision, it is necessary to find out whether this happened gradually or suddenly, whether he wears glasses, where and how he stores them.
If the patient is concerned about pain in or around the eyes, watery eyes, or redness, he should be reassured. Explain that decreased vision may be due to the patient’s adaptation to hospital conditions and taking medications.
The nursing care plan should be tailored to the patient's vision problems.
Organs of hearing. Before you begin examining them, you should ask the patient whether he hears well. If he complains of hearing loss, it is necessary to find out whether it affects both ears or one, whether it happened suddenly or gradually, and whether it was accompanied by discharge or pain. It is necessary to find out whether the patient wears a hearing aid, and if so, then the type of aid.
Using the information obtained about hearing loss and visual acuity, the nurse will be able to communicate effectively with the patient.
Olfactory organs. First, you need to find out how susceptible the patient is to colds, whether he often notices nasal congestion, discharge, itching, or whether he suffers from nosebleeds. If the patient has allergic rhinitis, the nature of the allergen and previously used methods of treating this disease should be clarified. Hay fever and pathology of the paranasal sinuses should be identified.
Oral cavity and pharynx. When examining the oral cavity, you need to pay attention to the condition of the patient’s teeth and gums, ulcerations on the tongue, dry mouth, if there are dentures, check their fit, find out the date of the last visit to the dentist.
Poorly fitting dentures can be an obstacle to communication with the patient and cause speech disorders, plaque on the tongue can cause a bad odor and decreased taste, and a sore throat and sore tongue can cause difficulty eating. All this must be taken into account when planning nursing care.

Upper body assessment

Head. First of all, you need to find out if the patient has complaints of headaches, dizziness, or whether there have been injuries. Headache is a very common occurrence in patients of all ages. It is necessary to find out its nature (constant or pulsating, acute or dull), localization, whether it arose for the first time or has a chronic course. With migraines, not only headaches are often observed, but also accompanying symptoms (nausea and vomiting).
Neck. Upon examination, various swellings, swollen glands, goiter, and pain are revealed.
Assessment of the condition of the mammary glands
During the examination, they find out whether the woman performs an independent examination of the mammary glands, whether there is a feeling of discomfort in the mammary gland, whether the woman is being seen by an oncologist, whether there are menstrual irregularities, whether there is engorgement and soreness of the glands in the premenstrual period.
When there is discharge from the nipple, they determine when it appeared, its color, consistency and quantity; they are secreted from one or both glands. The examination may reveal asymmetry of the mammary glands, engorgement, thickening, or absence of one or both mammary glands.
If the patient does not know how to independently perform a breast examination, training in these techniques can be included in the nursing care plan.
Pathology of the mammary glands is quite common in women, including young women. It must be remembered that the loss of a mammary gland can become a great psychological trauma for a woman and affect the satisfaction of her needs for sex. Nursing staff need to treat young patients who have undergone mastectomy with special tact and attention.

Assessment of the condition of the musculoskeletal system

To determine the state of this system, you must first find out whether the patient is bothered by pain in the joints, bones and muscles. If you complain of pain, you should find out its exact localization, area of ​​distribution, symmetry, irradiation, nature and intensity. It is important to determine what increases or decreases the pain, how physical activity affects it, and whether it is accompanied by any other symptoms.
Upon examination, deformities and limited mobility of the skeleton and joints are revealed. When joint mobility 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, comb his hair, brush his teeth, eat, dress, and wash freely. Limited mobility leads to limited self-care. Such patients are at risk of developing bedsores and infection and therefore require increased attention from nursing staff.
Respiratory system assessment
First of all, you need to pay attention to the change in the patient’s voice; frequency, depth, rhythm and type of breathing; excursion of the chest, assess the nature of shortness of breath, if any, the patient’s ability to tolerate physical activity, find out the date of the last x-ray examination.
Both acute and chronic pathology of the respiratory system can be accompanied by a cough. It is necessary to determine its nature, quantity and type of sputum, its smell. Particular attention should be paid to hemoptysis, chest pain, shortness of breath, since their cause, like cough, can be a serious pathology of the cardiovascular system.

Assessment of the state of the cardiovascular system

Pulse and blood pressure are determined, as a rule, before assessing the state of the cardiovascular system. When measuring the pulse, you need to pay attention to its symmetry in both arms, rhythm, frequency, filling, tension, deficit.
When a patient complains of pain in the heart area, it is necessary to clarify its nature, localization, irradiation, and duration. In the case of a long-term or recurrent illness, it is necessary to determine what medications the patient usually takes to relieve pain.
Patients are often bothered by palpitations. They say that the heart “freezes,” “pounds,” “jumps,” and notes painful sensations. It is necessary to find out what factors cause palpitations. It does not necessarily mean serious cardiac problems.
A characteristic sign of cardiovascular pathology is edema. They arise due to the accumulation of fluid in the tissues and cavities of the body. There are hidden (not visible during external examination) and obvious edema.
Obvious edema can be easily identified by changes in the relief of certain areas of the body. When the leg swells in the area of ​​the ankle joint and foot, where there are bends and bony protrusions, they are smoothed out. If, when you press on the skin and subcutaneous fat with your finger where they are closest to the bone (the middle third of the front surface of the leg), a dimple that does not disappear for a long time forms in this place, it means there is edema. The skin becomes dry, smooth, pale, insensitive to heat, and its protective properties are reduced.
The appearance of obvious edema is preceded by a latent period, during which a person’s body weight increases, the amount of urine excreted decreases, several liters of fluid are retained in the body, and hidden edema appears. It is important to be able to recognize them. This can be done by weighing yourself daily in the morning and determining the patient's fluid balance. Water balance is the ratio of the amount of fluid taken by a patient per day to the amount of urine excreted.
Then they find out the time and frequency of occurrence of edema, their localization, connection with excessive fluid or salt consumption, and with somatic diseases.
Edema can be local or general, mobile or immobile. With diseases of the heart and peripheral vessels, if the patient is not bedridden, orthostatic edema may appear in the lower parts of the body - on the feet and legs. Swelling of the eyelids and hands, if combined with swelling of other parts of the body, is observed in kidney diseases. An increase in waist size may be a sign of ascites (abdominal dropsy). Cachectic edema develops with extreme exhaustion of the body, for example in patients at the last stage of cancer.
Swelling can affect internal organs and cavities. The accumulation of transudate in the abdominal cavity is called ascites, in the pleural cavity - hydrothorax (dropsy); extensive swelling of the subcutaneous tissue is called anasarca.
Dizziness, fainting, numbness and tingling in the extremities are signs of hypoxia, a characteristic phenomenon in pathologies of the cardiovascular system and respiratory failure. They lead to an increased risk of falls and injury to the patient.
A detailed assessment of the state of the patient’s cardiovascular and respiratory systems allows us to judge the degree to which the need for oxygen, which occupies a leading place in the life of the body, is met.

Assessment of the state of the gastrointestinal tract (GIT)

Based on the information obtained about the state of the patient’s gastrointestinal tract, one can judge the degree to which his needs for food, drink, and removal of waste products from the body are met.
It is necessary to find out from the patient whether he has appetite disturbances, heartburn, nausea, vomiting (particular attention should be paid to bloody vomiting), belching, digestive disorders, and problems with swallowing.
It is advisable to begin the examination with the tongue - the mirror of the stomach. You should pay attention to plaque and bad breath, assess the patient’s appetite, find out his eating habits and eating patterns. It is necessary to note the shape and size of the abdomen, its symmetry. In case of emergency, nursing staff perform superficial palpation of the abdomen. In case of acute pain of unknown origin, it is necessary to urgently consult a doctor.
Essential indicators characterizing the state of the gastrointestinal tract are stool frequency, its color, and the amount of feces. Normally, a person passes stool at the same time every day. We can talk about its delay if it is absent within 48 hours. Fecal incontinence is often associated with diseases of the central nervous system. Defecation disorders can be caused not only by organic pathology, but also by the psychological state of the patient.
After a nursing interview and examination, the nurse records in the NIB the information received about bleeding from the rectum or tarry stools, hemorrhoids, constipation, diarrhea, abdominal pain, intolerance to certain foods, flatulence associated with pathology of the liver and gallbladder, jaundice, etc. Information about a colostomy or ileostomy will help to draw up an individual plan for nursing care, teaching relatives how to properly care for the patient.

Assessment of the urinary system

During a nursing interview and examination, it is necessary to assess the nature and frequency of urination in the patient, the color of urine, its transparency, and identify disorders of the urinary system (qualitative and quantitative). Urinary and fecal incontinence is not only a risk factor for the development of bedsores in a patient, but also a major psychological and social problem.
If the patient wears an indwelling catheter or has had a cisstomy, nursing staff need to plan measures to adapt the patient to the environment, as well as to prevent infection of the organs of his urinary system.

Assessment of the state of the endocrine system

When assessing the endocrine system, nursing staff need to pay attention to the patient’s hair growth pattern, the distribution of subcutaneous fat, and visible enlargement of the thyroid gland. Often, endocrine system disorders associated with changes in appearance become the cause of psychological discomfort for the patient.

Nervous system assessment

They find out whether the patient has had episodes of loss of consciousness, convulsions, and whether he sleeps well. It is necessary to ask the patient about his dreams, duration and nature of sleep (deep, calm or superficial, restless). It is important to find out whether the patient uses sleeping pills, if so, which ones, and how long ago he started using them.
The manifestation of neurological disorders in the patient may be headache, loss and change in sensitivity.
If there is tremors of the limbs or gait disturbances, the patient should find out whether he has had a head or spinal injury in the past. The actions of nursing staff should be aimed at ensuring the safety of such a patient during his stay in the hospital.
If the patient's motor activity is limited due to weakness, paresis or paralysis, the nursing care plan must include special measures to prevent bedsores.

Assessment of the state of the reproductive system

For women, the time of the first menstruation (menarche) is determined; regularity, duration, frequency, amount of discharge; date of last menstruation. It is necessary to find out whether the patient has bleeding between menstrual periods, whether she suffers from dysmenorrhea, premenstrual syndrome, and whether her health changes during menstruation.
Many girls are concerned about irregular or delayed menstruation. By asking questions, the nurse can understand the patient's level of knowledge about female genitalia.
In a middle-aged woman, you should find out whether and when her menstruation stopped, and whether its cessation was accompanied by any symptoms. You can also ask how she perceived this event, whether menopause affected her life in any way.
During a nursing interview and examination, discharge, itching, ulcerations, and swelling of the genital organs are revealed. The NIB notes previous venereal diseases and methods of their treatment; number of pregnancies, births, abortions; methods of preventing pregnancy; sexual preferences of the patient.
In men, the condition of the reproductive system is determined after checking the condition of the urinary tract. The questions asked are aimed at identifying local symptoms indicating sexual dysfunction.
It is very important to find out from the patient what conditions and circumstances (the patient’s general condition, medications taken, alcohol consumption, sexual experience, relationships between sexual partners) caused or contributed to sexual dysfunction. When talking with patients on this topic, nursing staff should use therapeutic communication techniques and the greatest sense of tact.
After completing the survey and examination, the initiative should be transferred to the patient by asking him a leading question: “What have we not talked about yet?” or asking: “Do you have any questions for me?” 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.
At the end of the examination, the nursing staff draws conclusions about the violation of the patient’s needs and records them in the NIB.
In the future, the dynamics of the patient’s condition should be displayed daily in the observation diary (NIB, p.) throughout the entire stay in the hospital.
The first steps at the beginning of the practical work of nursing staff can be cautious and uncertain. When examining patients, students are sometimes more worried than the patient himself. There is often a feeling of awkwardness and uncertainty. The interview turns into an interrogation, the examination drags on. Touching a patient's private parts causes a feeling of shame. In these cases, you should try to control yourself, stay calm, collected, and, if possible, confident. The skills of maintaining an educational medical history help in the future to competently and fully conduct a nursing interview.
If the conversation with the patient is already over, and you realize that you missed something important, you can come back and politely say that you need to clarify something. You cannot show your irritation, anxiety, or disgust. A medical worker has no right to have negative emotions at the patient’s bedside.
Self-confidence comes with time. With the acquisition of practical skills and abilities, the process of nursing examination becomes a familiar procedure, carried out without causing any particular inconvenience to the patient. Experienced nursing staff pays attention to the patient's reactions, and not to their own experiences. Improving professionalism for a true physician becomes his life’s work.

CONCLUSIONS
1. Collecting patient information at the first stage of the nursing process has a huge impact on the quality of subsequent nursing care. The main sources of information about the patient are himself, his relatives and friends, medical personnel, medical documentation, and special medical literature.
2. There are two types of information about the patient: subjective and objective. Collection of subjective information is carried out using a survey. First, personal data is recorded indicating the source of the information.
3. Subjective examination includes collection of main complaints, medical history, life history, self-assessment of the patient’s condition at the time of examination, family and psychological history.
4. During an objective examination, nursing staff determines the general condition of the patient, measures his height, body weight, temperature; assesses the condition of vision, hearing, skin and visible mucous membranes, musculoskeletal, respiratory, cardiovascular, urinary, reproductive, endocrine, nervous systems, and gastrointestinal tract.
5. Distinguish between clear and confused (inhibited, stunned, stupor) states of consciousness.
6. An objective examination reveals the patient’s position: active, passive and forced.
7. To assess whether a patient’s body weight of a certain height and age corresponds to the ideal body weight, special tables should be used.
8. When examining the skin and visible mucous membranes, their color, humidity and fat content, temperature, elasticity and turgor are assessed, and pathological elements on the skin and its appendages are identified.
9. When examining the musculoskeletal system, they first find out whether the patient has pain in the joints and muscles, if so, then their nature, bone deformities, and limitation of mobility.
When examining the respiratory system, the characteristics of breathing are determined; During the examination, pulse, blood pressure, pain in the heart area, and swelling are recorded.
When examining the gastrointestinal tract, appetite disturbances, heartburn, nausea, vomiting, belching, flatulence, constipation or diarrhea are noted.
When examining the urinary system, the nature and frequency of urination, the color of urine, its transparency are determined, and the fact of urinary incontinence is recorded.
When examining the endocrine system, the nature of hair growth, the distribution of fat on the body is determined, and an enlargement of the thyroid gland is detected.
As part of the examination of the nervous system, attention is paid to sleep patterns, tremors, gait disturbances, episodes of loss of consciousness, convulsions, sensory disturbances, etc.
When examining the reproductive system, a gynecological history is collected from women; In men, after clarifying the condition of the urinary tract, pathologies of the reproductive system are identified.

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