Definition of nursing, its goals and objectives. Nursing process. Description. Stages of a systematic approach to providing nursing care

The nursing process is a way of organizing the activities of a medical brother or nurse, applicable to any area of ​​activity of this employee. This method can be used in different healthcare settings.

The nursing process in therapy aims to ensure an adequate quality of life during the disease process by providing the patient with comfort, both psychosocial and spiritual and physical, in accordance with his spiritual values ​​and culture.

This method of organizing the activities of a health worker has a number of advantages. First of all, the nursing process is individual. It also has a certain consistency and efficiency in the use of resources and time. This method is universal; within its framework, it provides the possibility of widespread application of activity standards that have a scientific basis. It is also important that when planning and implementing care, there is also interaction between the patient’s family and the staff of the medical institution.

Stages of the nursing process

1. Examination.
2. Problem identification (diagnosis).
3. Care planning.
4. Provide care as planned.
5. Correction (if necessary) of care, evaluation of effectiveness.

The nursing process involves ensuring maximum patient comfort. This is a significant factor contributing to the preservation of health and alleviation of a person’s condition.

Patient care is considered qualified if it meets the necessary requirements: individuality, systematicity, and scientific character.

In the process of planning and caring for a patient, it is important not so much to find out the causes of various disorders, but to examine the external manifestations of pathology, which are the result of a deep disorder in the body’s activity and one of the main causes of discomfort.

Before starting a diagnosis, it is necessary to collect the necessary information about the patient. The first stage also includes the collection of information such as medical history, doctor’s diagnosis, its nature, duration, intensity, etc.

After systematizing the information, diagnostics are carried out. Today, the concept of nursing diagnosis refers to the identification of a certain list. This list includes stress, pain, hyperthermia, anxiety, self-hygiene, physical inactivity, etc.

Once a “nursing diagnosis” has been established, care planning occurs. The medical professional formulates care, suggests expected timing and results. At this stage, the nursing process also includes the formulation of techniques, methods, methods, actions through which the planned goals and assigned tasks will be achieved.

Care planning presupposes a clear scheme in accordance with which conditions that, to one degree or another, complicate the disease will be eliminated. If there is a plan, the work of the staff is clearly organized and coordinated.

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

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

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

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

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

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

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

Purpose of the fifth stage of the nursing process- determine to what extent the goals have been achieved.

At this stage the nurse:

Ø determines the achievement of the goal;

Ø compares with the expected result;

Ø formulates conclusions;

Ø makes appropriate notes in documents (nursing medical records) about the effectiveness of the care plan.

The patient's new condition may be:

Ø better than the previous condition;

Ø no changes;

Ø worse than the previous condition.

If goals are not achieved, the nurse should:

Ø identify the cause - search for mistakes made;

Ø change the goal itself - make it more realistic;

Ø reconsider the deadlines for achieving the goal;

Ø make the necessary adjustments to the nursing care plan.

PATIENT NEEDS

A need is a physiological or psychological deficiency that a person experiences throughout his life and must constantly be replenished for harmonious growth and development. Moreover, it is very important that he must do this on his own, only then will he experience a state of complete comfort. If the satisfaction of at least one of the needs is violated, a state of discomfort develops. For example, during the course of his life, a person constantly experiences a shortage of food and must make up for it by satisfying the need to EAT. A seriously ill patient cannot feed himself, which leads him to a state of discomfort. Even if we feed him, the discomfort will continue, since independence in satisfying this need has been lost.

The nurse, due to her knowledge and skills, is able to determine not the patient’s illness, but to determine the violation in meeting needs and create conditions to satisfy these needs.

To do this, the nurse must collect complete information about her patient: how he meets his needs, that is, carry out the first stage of the nursing process. Only by clearly and distinctly imagining the satisfaction of what needs is disturbed in the patient can a nurse formulate the problems of nursing care, set goals of care, think through and draw up an individual care plan, implement it and evaluate the results. Only by imagining the patient as an individual, as a single physiological and psychosocial whole, can a nurse count on understanding and supporting the patient in organizing his care and effectively guiding him towards improving his condition.

Of all human needs, psychologist A. Maslow identified 14 basic vital needs. These include needs:

4. Highlight

5. Sleep, rest

6. Be clean

7. Dress and undress

8. Maintain temperature

10. Avoid danger

11. Move

12. Communicate

13. Have life values

14. Play, study, work

HIERARCHY OF BASIC VITAL NEEDS ACCORDING TO A. MALOW

The first stage of A. Maslow's pyramid is represented by the lower physiological needs, without which life in the biological sense of the word is impossible. If a person does not satisfy these needs, then he will simply die, like any living creature on Earth. These are survival needs. These include needs:

4. Highlight

Throughout his life, a person grows, develops, and is constantly in contact with his environment. In this regard, he has such vital needs that he needs to satisfy for harmonious growth and development in this environment. These are needs that ensure a person’s own safety: protection from natural elements, diseases, social phenomena, life failures, and stress. They form the second stage of Maslow's pyramid. These are the needs:

5. Sleep, rest

6. Be clean

7. Dress and undress

8. Maintain temperature

9. Maintain condition, or be healthy

10. Avoid danger

11. Move

Both of these steps form the foundation (base, support) of Maslow’s pyramid.

The third stage of A. Maslow's pyramid includes the need for belonging. Throughout his life, a person needs to have support, belong to society, and be accepted and understood by this society. He needs to have information about his environment. He achieves this by satisfying his need:

12. COMMUNICATE

Life in society has led to the emergence of needs for ACHIEVEMENT OF SUCCESS: in work, life, family, the desire for harmony, beauty, order. These needs make up the 4th stage of Maslow's pyramid and are represented by the need to HAVE LIFE VALUES.

And finally, the top of the pyramid, the 5th stage, consists of the needs for SERVICE, which ensure a person’s self-realization and development as an individual. It is the need to LEARN, WORK AND PLAY. See below for a detailed description of each need.

Let's look at Maslow's pyramid as a whole (see Figure N1), and we will see that until a person satisfies the needs that make up its lower steps, he will not be able to satisfy higher psychosocial needs.

All these needs must be satisfied by a person constantly in the course of his life in order to achieve physical, social and creative well-being.

DETAILED CHARACTERISTICS OF EACH NEED

Need to BREATHE:

Concept of need

The need to BREATHE ensures constant gas exchange between the body and the environment

The nurse learns about the violation of the need by conducting an objective and subjective examination of the patient.

1. Subjective examination:

(carried out during a conversation with the patient, identifying his complaints).

If the need to breathe is impaired, the patient may have COMPLAINTS of:

Ø chest pain

In a conversation with the patient, the nurse also identifies RISK FACTORS that affect the need to breathe:

Ø smoking;

Ø working or living in a polluted or dusty atmosphere.

2. Objective examination:

(the nurse carries out a general examination of the patient).

An objective examination may reveal:

Ø change in skin color - cyanosis (cyanosis)

Ø difficulty breathing through the nose

Ø change in frequency, rhythm or depth of breathing

Ø fever

1. Shortness of breath;

2. Cough;

3. Chest pain associated with breathing;

4. Choking;

5. Risk of breathing problems due to smoking;

6. High risk of suffocation.

1. the nurse will provide a flow of fresh air into the room where the patient is;

2. the nurse will give the patient a forced position that makes breathing easier for the patient (if necessary, drainage);

3. the nurse will provide oxygen therapy to the patient;

4. the nurse will carry out measures to cleanse the respiratory tract;

5. The nurse will perform simple physical procedures in the absence of contraindications.

THE NEED IS:

Concept of need

By satisfying the need to EAT, a person delivers food to the body - the main source of energy and nutrients necessary for normal life. Food is one of the main resources for health.

Some characteristic signs during nursing examination:

1. Subjective examination:

Appetite disturbance

Belching

Nausea

Stomach ache

RISK FACTORS influencing the need to eat:

Error in diet

Eating disorder

Binge eating

Alcohol abuse

Missing teeth, carious teeth

2. Objective examination:

Smell from the mouth

Presence of carious teeth

Vomiting during examination

Some examples of possible nursing diagnoses:

1) abdominal pain;

2) nausea;

4) loss of appetite;

5) excessive nutrition, exceeding the needs of the body;

6) obesity.

Some examples of possible nurse involvement in meeting a need:

1) the nurse will ensure compliance with the prescribed diet;

2) the nurse will create a forced position for the patient;

3) the nurse will assist the patient with vomiting;

4) the nurse will teach the patient techniques to combat nausea and belching;

5) the nurse will conduct a conversation with the patient and his relatives about the nature of the diet prescribed to him and the need to comply with it.

Need to DRINK:

Concept of need

By satisfying the need to DRINK, a person delivers water to the body. Life is impossible without water, since all vital chemical reactions in cells occur only in aqueous solutions.

1. Subjective examination:

Dry mouth

RISK FACTORS influencing the need to DRINK:

Drinking poor quality water

Consuming insufficient or excess water

2. Objective examination:

Dry skin and mucous membranes

Some examples of possible nursing diagnoses:

2) dry mouth;

3) dehydration.

Some examples of possible nurse involvement in meeting a need:

1) the nurse will provide the patient with a rational drinking regime;

2) the nurse will talk with the patient about the need to drink good-quality water.

Need to highlight:

Concept of need

By satisfying the need to excrete, a person removes from the body harmful substances that are formed in the process of life, waste food residues.

This need is provided by the function of the urinary and digestive systems, skin and respiratory organs.

The most characteristic signs during a nursing examination:

1. Subjective examination:

Bloating

Disorders of urination and urine formation

Lack of urine

Small amount of urine

Increased amount of urine

Frequent painful urination

RISK FACTORS influencing the need to excrete:

Diet disorders

Sedentary lifestyle

Hypothermia

2. Objective examination:

Swelling is obvious;

Hidden edema;

Change in stool character;

Dry skin, decreased firmness and elasticity of the skin, skin coloring;

Change in the amount of urine;

Visual change in urine.

Some examples of possible nursing diagnoses:

3) lack of urine (anuria);

4) acute urinary retention;

5) the risk of diaper rash in the area of ​​the crotch folds.

Some examples of possible nurse involvement in meeting a need:

1) the nurse will provide the patient with the prescribed diet and drinking regimen;

2) the nurse will provide the patient with an individual bedpan and urinal;

3) the nurse will train the patient and, if necessary, carry out hygienic measures herself after physiological functions;

4) the nurse will teach the patient the skills of exercise therapy and self-massage of the abdominal area;

5) the nurse will talk with the patient and relatives about the nature of the prescribed diet and the need to comply with it.

Need to SLEEP:

Concept of need

The burden of everyday worries and affairs weighs down a person, causing concern, anxiety, and stress throughout the day. This leads to depletion of the nervous system, and therefore to disruption of the functions of various organs.

By satisfying the need to SLEEP, a person overcomes these harmful effects and restores the body’s strength.

The most characteristic signs during a nursing examination:

1. Subjective examination:

Insomnia

Sleep disturbance

Intermittent sleep

Drowsiness

Falling asleep in the morning

RISK FACTORS AFFECTING THE NEED TO SLEEP AND REST:

No rest during the day

Excessive workload

No vacations or days off

2. Objective examination:

Facial expression (fatigue, exhaustion, dull look, poor facial expressions);

Some examples of possible nursing diagnoses:

1. lack of sleep;

2. sleep disturbance.

Some examples of possible nurse involvement in meeting a need:

1. The nurse will provide the patient with the prescribed regimen;

2. The nurse will teach the client skills to help regulate sleep;

3. For example: a glass of warm milk with a spoon of honey at night, a walk in the fresh air before bed, auto-training skills

4. The nurse will talk with the patient about the need for daily rest;

5. The nurse will teach the patient how to create a daily routine: frequent changes of activities, rest.

Need

MAINTAIN A CONSTANT BODY TEMPERATURE:

Concept of need

The normal functioning of organs and tissues is impossible without the temperature constancy of the human internal environment. This is ensured:

1) through complex regulation of heat production and heat transfer from the body;

2) clothes for the season;

3) maintaining the microclimate of the premises where a person is located.

The most characteristic signs during a nursing examination:

1. Subjective examination:

Sweating

Feeling hot

Headache

Aches in the body, joints

Dry mouth

2. Objective examination:

Facial hyperemia

The appearance of goose bumps

Skin that is hot to the touch

Dry skin and mucous membranes

Cracks on lips

Change in body temperature

Increased heart rate and respiratory rate

Wet skin

Deviation in room temperature conditions

Some examples of possible nursing diagnoses:

1) low-grade fever second<^ период;

2) pyretic fever first period;

3) hypothermia.

Some examples of possible nurse involvement in meeting a need:

1) the nurse will provide the patient with peace;

2) the nurse will provide care for the patient’s skin and mucous membranes;

3) the nurse will provide the patient with plenty of fortified drinks;

4) the nurse will warm or cool the patient if necessary;

5) the nurse will ensure that you take easily digestible food;

6) the nurse will ensure that the patient’s body temperature profile is measured;

7) the nurse will constantly monitor the patient’s condition;

8) the nurse will control the temperature of the room.

The need to BE CLEAN:

The concept of need.

Human skin and mucous membranes participate in thermoregulation of the body, remove toxins from the body, and perform a protective function. Therefore, in order to function normally, the skin and mucous membranes must be clean.

In addition, maintaining a clean body contributes to a person’s psychological comfort.

The most characteristic signs during a nursing examination:

1. Subjective examination:

Itchy skin

Pain and burning in the area of ​​natural folds

2. Objective examination:

Skin changes in the area of ​​natural folds

Hyperemia

Integrity violation

Unpleasant smell

Bad breath

Dirty laundry

Ungroomed nails

Greasy hair

Some examples of possible nursing diagnoses:

1) lack of knowledge about personal hygiene;

2) high risk of infection associated with violation of the integrity of the skin and mucous membranes;

3) lack of self-hygiene;

4) violation of the integrity of the skin in the area of ​​natural folds.

Some examples of possible nurse involvement in meeting a need:

1) the nurse will carry out a set of hygiene measures for the patient;

2) the nurse will teach the patient personal hygiene skills;

3) the nurse will talk with the patient about the need for personal hygiene;

4) the nurse will monitor the patient’s hygiene skills on a daily basis.

Need to MOVE:

Concept of need

Movement is life! Movement strengthens muscles, improves blood circulation, nutrition of cells and tissues, and the release of harmful substances from the body.

Improves the functioning of internal organs and maintains mood.

The most characteristic signs during a nursing examination:

1. Subjective examination:

Inability or limitation of physical activity due to:

Weakness

Lack of a limb

Presence of paralysis

Mental disorder

RISK FACTORS influencing the need to MOVE:

Physical inactivity

Sedentary work

Constant driving

2. Objective examination:

Pain when moving

Changes in the joint area

Hyperemia

Local temperature rise

Changing the configuration

Passive position in bed

Missing limb

1) limitation of physical activity;

2) lack of physical activity;

3) the risk of bedsores;

4) bedsores.

Some examples of possible nurse involvement in meeting a need:

1) in the absence of movement or its sharp limitation, the nurse will carry out a set of measures to care for the patient;

2) the nurse will carry out simple exercise therapy and massage as prescribed;

3) the nurse will teach the patient the necessary simple complex of exercise therapy and self-massage and monitor its implementation;

4) the nurse will talk with the patient about physical inactivity and its consequences.

Need to get dressed or undressed:

Concept of need

To ensure a constant body temperature, it is not enough just to regulate heat production and heat transfer by the body itself. A person also has to regulate body temperature with clothing depending on climatic conditions. Clothing selected according to age, gender, season, and environment provides the patient with moral satisfaction.

The most characteristic signs during a nursing examination:

1. Subjective examination:

Inability to undress or dress independently

Pain when moving

Paralysis of limbs

Sharp weakness

Mental disorders

2. Objective examination:

The patient cannot dress or undress independently

The patient's clothing does not fit correctly (small or large), making it difficult to move

Clothes are not appropriate for the season (lack of warm clothes in winter)

Some examples of possible nursing diagnoses:

1) inability to dress and undress independently;

2) high risk of hypothermia;

3) high risk of overheating;

4) violation of a comfortable state due to incorrectly selected clothing.

Some examples of possible nurse involvement in meeting a need:

1) the nurse will help the patient undress and dress;

2) the nurse will dress the patient in clothing appropriate for the patient;

3) the nurse will talk with the patient about the need to dress according to the season.

NEED TO BE HEALTHY:

Concept of need

This need reflects the desire of every person for health, reflects the patient’s independence in meeting his basic vital needs. Failure to satisfy the need to be healthy occurs when a person loses independence in care. For example, the patient is limited in physical activity (bed rest or strict bed rest). In this state, he cannot independently satisfy his needs, which leads to a violation of the need to be healthy. Another example is when the patient is in an emergency condition (massive bleeding, collapse, etc.). At the same time, it is also impossible to satisfy needs independently.

The most characteristic signs during a nursing examination:

1. Subjective examination:

In the first case, the nurse determines which needs the patient can satisfy independently, that is, independently of anyone, and in meeting which needs he needs help and to what extent.

For example:

Ø can the patient independently carry out personal hygiene measures;

Ø does he need outside help with physiological functions (take him to the toilet, bring him a bedpan);

Ø can the patient dress and undress independently;

Ø can the patient move without assistance;

Ø Can he eat and drink independently?

In the second case, the nurse constantly monitors the patient’s condition and, if it worsens, will call a doctor and provide emergency pre-medical care before he arrives.

Some examples of possible nursing diagnoses:

1. deficit of self-care.

Some examples of possible nurse involvement in meeting a need:

1) the nurse will provide direct assistance to the patient in activities of daily living:

Ø washes

Ø delivers the vessel

Ø dresses, undresses

2) taking into account that the main thing for a person is independence and freedom, the nurse, at the slightest opportunity, will create conditions for the patient to independently satisfy his violated needs. For example:

As the physical activity regime increases, the nurse does not wash him herself, but gives him washing supplies in bed

3) the nurse will teach the patient skills of daily living in conditions of his disability.

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

BRIEF DESCRIPTION OF THE MAIN STEPSNURSING

PROCESS

Stage I of the nursing process is collecting information.

(SUBJECTIVE AND OBJECTIVE EXAMINATION)

Nursing process is a method of organizing and providing nursing care. The essence

nursing is about caring for a sick person and how a nurse

provides this care. Regardless of the form, the nursing care plan must

provide for continuity of the nursing process. In addition to the nursing plan

documentation contains patient biographical information and nursing assessment results

his condition.

When taking notes, you should present information concisely, clearly and unambiguously, using

only common abbreviations.

At the first contact with the patient, the nurse begins to collect information. IN

as soon as possible after a person enters the health care system

An initial assessment of the situation and its documentation is carried out. Ideally this initial

the assessment includes a detailed medical history. Where possible, the patient is asked

express your own judgment and talk about existing needs. Then

the information received is analyzed and used as the basis for determining needs

person in care. Gathering information is very important. Incorrect information entails

wrong actions. Insufficient information is accompanied by inadequate

actions.

Patient communication strategy

Subjective examination:

You must be sure that your conversation will take place in a quiet

informal setting without distraction and will not be interrupted.

To establish a trusting relationship with the patient, the nurse

must introduce herself, stating her name, position and state the purpose of the conversation.

Call the patient by name and patronymic, and by “you”. Be friendly

participation and care.

Use exclusively positive intonation of your voice. Be

calm and unhurried. Do not show annoyance or irritation.

Speak clearly, slowly, distinctly. Use patient-friendly

terminology If you doubt that he understands you, ask what

he puts into this or that concept. Encourage your patient to ask questions.

Allow the patient to finish the sentence, even if he is excessively verbose. If

the question needs to be repeated, rephrase it for better understanding.

Do not start the conversation with personal, sensitive questions.

To formulate a report on the patient's problems and complete a nursing history

illness with a nursing process map according to which you will work. Ask: "What

brought you to our medical institution?” Listen carefully to his opinion about your

condition, as he assesses it. Does he consider himself seriously ill, slightly ill, to what extent?

focused on his problems, what results he expects from being in this

medical institution (hopes to recover, does not wait for the improvement of the condition and the solution of his

problems, thinks that his condition will remain unchanged).

Then ask, “What is bothering you?”

The patient's complaints are determined at the moment, he is given the opportunity

Express your feelings yourself. The student then asks questions to

systematize and detail complaints. If the patient is in pain, you should

to figure out:

Localization;

Irradiation;

Time of appearance;

Character (aching, stabbing, pressing);

Duration (constant, paroxysmal);

Causes causing or increasing pain (movement, eating);

Concomitant phenomena (weakness, nausea).

Particular attention should be paid to the “Medical History” section. Need to check with

how long does he consider himself sick (the first signs of the disease). Should be paid

attention to the patient’s condition immediately before the disease, whether there were

mental trauma, overwork, hypothermia, eating errors.

Onset of the disease: when and how the first manifestations appeared, their nature.

In case of a chronic course of the disease, it is necessary to find out how it progressed during

this time, what manifested itself, whether there were exacerbations, their frequency, duration

remissions.

Conducted research (list which).

Treatment and its effectiveness (groups of drugs, their effect

applications).

Answers to the questions in the Medical History section should be written down in the nursing

medical history is short, clear, to the point.

Questions about sexual life and gynecological history should be asked in

tactfully, without attracting the attention of the patient’s surroundings.

When determining allergy history, it should be noted which specific medications

means, food products, household substances cannot be tolerated by the patient.

When identifying spiritual status, you should not express your opinion about

moral values ​​of the patient.

In the social status of the patient, attention is paid to the health of his close relatives

(parents, brothers, sisters), focusing on the pathology that is important for

disease of this patient.

Objective examination.

Measure blood pressure, body temperature, examine pulse, respiratory rate

movements, determine the condition of the skin. For an objective examination, a nurse

uses his vision, hearing, touch, and smell.

An additional source of information can be laboratory and

instrumental research. When collecting data, the nursing model should be taken into account

cases received in this hospital. Taking into account the recommendations of WHO/Europe. Carrying out an examination

patient, you need to find out:

the state of his health, taking into account each of the 14 fundamental needs,

what this person considers normal for himself in connection with each indicated

need;

what this person does or what help he needs to satisfy each

needs;

how and to what extent, the person’s current state of health or his social

needs prevent him from providing self-care or assistance at home;

what potential difficulties or problems can be foreseen in connection with the change

his health;

a person’s ability to self-care, what help a person can have from his friends and

relatives;

medical diagnosis, principles of treatment and prognosis;

previous diseases and social problems.

The results obtained during the nursing examination are recorded in

nursing medical history.

Physical status information may reflect normal manifestations

life activity, as well as changes associated with a certain stage of development

(e.g. infant, adult, elderly person) and changes caused by

disease.

Information about the state of mind allows you to assess emotional health and

changes in behavior due to illness.

Information about social health allows you to assess the patient’s capabilities

carry out self-care at home.

Stage II of the nursing process - nursing diagnosis.

After the initial assessment of the patient's condition and recording the information received, the nurse

summarizes, analyzes the results obtained and draws certain conclusions. They

become those problems, i.e. nursing diagnoses that are the subject

nursing care.

You should highlight the nursing diagnoses:

1. Real, those that occur in the patient today will exist tomorrow and in the future

throughout the duration of nursing care in a hospital.

2. Potential- problems that may arise for the patient in the process of caring for

it or be caused by an underlying disease.

Nursing diagnoses are recorded in the nursing record after section

"Nursing analysis of laboratory and instrumental data." Then you proceed to

work on the nursing process map. Fill in the fields highlighted in it. Special

Pay attention to planning patient care and its implementation.

Stage III of the nursing process - planning nursing interventions

patient-centered goals and establishing strategies to achieve goals. In

planning time, priorities are set, goals are determined, expected

results and a nursing care plan is formed. In addition to communicating with the patient and his

As a family, the sister consults with colleagues and studies relevant literature. After

establishing specific medical diagnoses, the nurse determines priorities in

according to the severity of the diagnosis. Prioritization is a method by which

patient and nurse work together to make diagnoses based on wants, needs, and

patient safety. Since the patient has several diagnoses, the nurse cannot

begin care for all of them simultaneously after they are established.

The nurse selects priority diagnoses depending on the urgency, nature

prescribed treatment, interactions between diagnoses. Priorities are classified

as primary, intermediate and secondary. Nursing diagnoses that may entail

the death of the patient, if urgent assistance is not provided, has primary priority.

Intermediate priority nursing diagnoses include non-extreme and

non-life-threatening needs of the patient. Secondary priority nursing diagnoses:

patient needs that are not directly related to the disease or its prognosis.

There are two types of goals allocated for patients: short-term (less than one

weeks); long-term (weeks, months, often after discharge).

Short-term goals are those that must be achieved in a short period

time, usually less than a week.

Long-term goals are those that can be achieved over a longer period of time.

a period of time over weeks and months.

These goals can be determined when the patient is discharged and when he returns home.

They are aimed at prevention, rehabilitation, and acquisition of knowledge about health. If

long-term goals are not highlighted, this disempowers the patient and nurse

Plan for continued nursing care upon discharge. The expected result is

a special step concept that leads to achieving goals and determining the cause

diseases for diagnosis. The result is behavior change

patient's response to nursing care. Result means change

the patient's condition from the point of view of physiology, social, emotional and spiritual

condition. Expected results arise from short and long term goals,

patient-centered and based on nursing diagnoses.

IY stage of the nursing process - implementation of the care plan.

After formulating goals, the nurse develops a nursing care plan, i.e., a written nursing guide that is a detailed listing of the nurse's specific actions necessary to achieve nursing goals. The plan of care coordinates nursing care, ensures continuation of care, and lists the outcome measures by which

care is assessed.

IY stage of the nursing process = assessment of the effectiveness of care. Systematic

the assessment process requires the nurse to think analytically when comparing what is expected

results with those achieved. As the pursuit of the goal fails, the nurse must

identify the reason why the entire nursing process is repeated from the beginning in search of

mistake made.

For example:

The patient care plan should reflect the principles of care, i.e. the main activities for

patient care aimed at solving the patient’s problem.

Fix them in

column “Nature of nursing intervention”.

In the column “Implementation of the nursing care plan” you write what exactly you did,

When implementing the patient care plan, he listed all his actions.

You must evaluate your results in accordance with your goals.

Short-term goals - daily or hourly (in emergency situations), long-term