The nursing process consists of five main stages. Nursing process. Description. Stages Stage III. Implementation of a plan. Observation
The nurse asks the patient about:- previous illnesses - the patient’s attitude towards alcohol; - nutritional characteristics; - allergic reactions to medications, food, etc.; - duration of the disease, frequency of exacerbations; - taking medications (name of the drug, dose, regularity of use, tolerability); - patient complaints at the time of examination. The nurse conducts an objective examination:- examination of the condition of the skin and mucous membranes; the color of the palms, the presence of scratching, spider veins, and dilated veins on the anterior abdominal wall; - determination of the patient’s body weight; - body temperature measurement; pulse examination; - blood pressure measurement; - assessment of the size of the abdomen (presence of ascites); - superficial palpation of the abdomen.
All data from the nursing examination are documented in the nursing medical history by filling out the “Primary Nursing Assessment Sheet”
2.2.2. Stage II of the nursing process is identifying the patient's problems.
Goal: to identify the patient’s difficulties and contradictions that have arisen as a result of the inability to satisfy one or more needs.
The nurse examines the patient's external reaction to what is happening to him and identifies the patient's problems.
Patient problems:
Valid (real):- pain in the lumbar region; - oliguria; - weakness, fatigue;
Headache; - sleep disturbance; - irritability; - the need to constantly take medications; - lack of information about the disease; the need to stop drinking alcohol; - lack of self-care. Potential:-CRF (chronic renal failure) - the risk of developing renal encephalopathy;
Possibility of becoming disabled.
2.2.3. Stage III of the nursing process - planning nursing care.
The nurse must be able to set specific goals and draw up a realistic care plan with motivation for each step (Table 1).
Table 1
|
Motivation |
|
|
1. Provide nutrition in accordance with a gentle diet, limiting physical activity. |
To improve kidney function |
|
2. Ensure personal hygiene of the skin and mucous membranes (wiping, shower). |
Prevention of itchy skin |
|
3.Monitor the frequency of stools |
Prevent bowel retention |
|
4. Monitor the patient’s functional state (pulse, blood pressure, respiratory rate) |
For timely recognition and assistance in case of complications |
|
5.Follow doctor’s orders in a timely and correct manner |
For effective treatment |
|
6. Conduct conversations: about the need to adhere to diet and nutrition; about the rules for taking medications; about the side effects of drug therapy |
For effective treatment and prevention of complications |
|
7.Provide preparation for research |
To carry out research correctly |
|
8. Monitor weight and diuresis |
For status monitoring |
|
9. Observe the patient’s mental state |
Psycho-emotional relief |
The care plan must be recorded in the nursing documentation for the implementation of the nursing process.
2.2.4. IV stage of the nursing process - implementation of the nursing care plan.
The nurse implements the planned plan of care.
1. Conducting a conversation with the patient and his relatives about the need to strictly follow a diet with limited animal fats and sufficient amounts of proteins, carbohydrates and vitamins. Give a reminder about nutrition (Appendix 2). Spicy, fried and pickled foods are prohibited. If signs of renal encephalopathy appear, limit protein foods. Meals are fractional, at least 4-5 times a day. The consumption of any alcohol is strictly prohibited. Monitoring compliance with the diet - predominantly dairy-vegetable fortified foods using mainly vegetable fats.
2. Providing the patient with ward conditions. In weakened patients, bed rest is provided, which provides general care and a comfortable position in bed for the patient. Limiting physical activity. 3. Personal hygiene, careful care of the skin and mucous membranes in case of dryness, scratching and itching of the skin. 4. Informing the patient about drug treatment (medicines, their dose, rules of administration, side effects, tolerability).
6. Providing the patient with conditions for proper sleep. 7. Monitoring: - the patient’s compliance with diet, nutrition, and physical activity; - transfers to the patient; - regular use of medications; - daily diuresis; - body weight; - condition of the skin; - symptoms of bleeding (pulse and blood pressure). 8. Preparing the patient for laboratory and instrumental research methods. 9. Compliance with medical-protective and sanitary-epidemiological regimes.
10. Motivating the patient to follow the doctor’s orders and the nurse’s recommendations.
11. Monitoring the patient’s mental state.
1. Nursing examination.
2. Nursing diagnosis.
3. Planning nursing intervention.
4. R implementation of the nursing plan (nursing intervention).
5. Evaluation of the result.
The stages are sequential and interconnected.
Stage 1 SP - nursing examination.
This is the collection of information about the patient’s health status, his personality, lifestyle and the reflection of the obtained data in the nursing medical history.
Target: creation of an information base about the patient.
The foundation of nursing assessment is the doctrine of the basic vital needs of a person.
Need there is a physiological and (or) psychological deficiency of what is essential for human health and well-being.
In nursing practice, Virginia Henderson's classification of needs is used ( Model of nursing W. Henderson, 1966), which reduced all their diversity to the 14 most important and called them types of daily activities. In her work, V. Henderson used A. Maslow’s theory of the hierarchy of needs (1943). According to his theory, some needs for a person are more significant than others. This allowed A. Maslow to classify them according to 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.
Nursing process - a method of scientifically based and practical implementation by a nurse of her duties in providing care to a patient.
Target nursing process - ensuring an acceptable quality of life for a patient in illness, that is, ensuring the maximum possible physical, mental and spiritual comfort for the patient in his state.
Implications of the nursing process for nursing practice:
Identifies the patient's specific care needs and ensures patient participation in care;
Contributes to the selection of care priorities from a range of existing needs and predicts expected care outcomes;
Determines the nurse's action plan and strategy to meet the patient's needs;
With its help, the effectiveness of the work carried out by the sister and her professionalism are assessed. And most importantly, the nursing process ensures the quality of nursing care.
Nursing process consists of five stages, each of which is an essential stage in solving a priority problem and is closely related to the other four:
Nursing performance assessment
nursing process survey
Interpretation implementation
nursing plan data received
and formulation
priority problem
(nursing diagnostics) planning
nursing care
Conclusion: The nursing process is a sequential change of actions (stages) performed by the nurse in relation to the patient with the aim of preventing, reducing and minimizing the problems and difficulties associated with his health.
First stage - nursing examination.
This is the ongoing process of collecting and recording information about the patient's health status and the degree to which the patient's needs are being met.
Target stage – creation of an information base about the patient.
Types of nursing information
Subjective Objective
Information sources
Methods for obtaining information.
The nurse should collect information and evaluate the following parameter groups :
1. The state of the main functional systems of the body.
2. Emotional and intellectual background, range of adaptation to stress.
3. The ability to perform self-care.
4. Sociological data.
5. Environmental data (“risk factors”).
The collected data is recorded in the nursing medical history using a specific form.
Nursing history - a legal protocol document of the independent, professional activity of a nurse within her competence.
Data documentation makes it possible to:
· identify gaps in patient care,
· discloses full information about the work done,
· clearly shows the dynamics of the patient’s condition,
· ensures continuity and a systematic approach in organizing nursing care,
· Helps to exercise self- and mutual control.
You can find a sample nursing case history in the appendix.
Conclusion: Thus, at stage 1, the nurse receives two types of information:
subjective– includes feelings, emotions, sensations (complaints) of the patient himself
regarding your health;
objective- data obtained as a result of observations and examinations carried out by a nurse.
Second phase - nursing diagnosis.
This is the formation of present or possible future deviations from a comfortable state and the formulation of a priority problem / nursing diagnosis /.
Target stage - identifying the problems that arise in the patient, identifying the factors causing the development of these problems, identifying those qualities of the patient that can help prevent or resolve his problems.
From 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).
Patient problems.
Present / existing / Potential
* Physiological
* Social
* Psychological
* Spiritual
Existing– these are the problems that are bothering the patient at the moment:
Potential– those that do not exist, but may appear over time.
By priority, problems are classified as primary, intermediate and secondary (priorities are therefore classified similarly).
TO primary include problems associated with increased risk and requiring emergency assistance.
Intermediate do not pose a serious risk and allow for delay of nursing intervention.
Secondary problems are not directly related to the disease and its prognosis.
Priority issue/nursing diagnosis/ is a clinical judgment of a nurse that describes the nature of the patient's existing or potential response to an illness or condition, preferably indicating the likely cause of this reaction.
In 1987, at the first international conference in Calgary, much attention was paid to the problems of nursing diagnostics.
In 1991, nursing diagnosis was included in the US standards of nursing practice.
In 1992, the Tenth US Conference of Nursing approved a list of 109 nursing diagnoses.
Soon the concept of “nursing diagnosis” becomes international.
Currently in the Russian Federation the concept of “nursing diagnosis” does not have official recognition.
Based on the patient's identified problems, the nurse begins to make a diagnosis.
Distinctive features of nursing and medical diagnoses:
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.
Conclusion: problems arise for the patient when there are difficulties in meeting needs. The nurse does not consider the disease itself, but the patient's response to the disease and changes in health status.
Third stage - nursing care planning.
E then defining goals and drawing up an individual nursing intervention plan separately for each patient’s problem, in accordance with the order of their importance.
Target: Based on the patient’s needs, identify priority problems, develop a strategy for achieving goals (plan), and determine the criterion for their implementation.
During planning, the nurse sets priorities, defines goals, expected outcomes, and formulates a plan of nursing care.
Priority is what most burdens the patient at the moment, is the main thing for him now or can worsen his health and well-being.
Criteria for choosing the priority/significance/ of the patient’s problems:
The main thing, in the opinion of the patient himself, is the most painful and detrimental for him, or interferes with the implementation of self-care;
Problems that contribute to the worsening of the disease and a high risk of complications.
In nursing practice target - is the expected specific result of nursing intervention for a specific patient problem.
When setting goals, the nurse considers the following:
· must be real, achievable, diagnostic (verifiable),
· have specific deadlines for achieving them:
Short-term – no more than 1 week,
Long-term – several weeks, months, years,
· be within nursing competence, not medical competence,
Reduction or complete disappearance of symptoms 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,
· formulated on behalf of the patient/family/, i.e. be understandable to the patient.
Goal structure
fulfillment criterion condition
(action) (date, time, distance) (with the help of someone or something)
For example, the patient will walk 7 meters with crutches on the eighth day.
Plan is a written care guide that contains a detailed listing of all the actions of the nurse, in agreement with the patient, necessary to achieve the goals.
Plan:
· Coordinates the work of the nursing team,
· ensures continuity of nursing care,
· Helps maintain communication with other health professionals,
· reduces the risk of incompetent or careless care,
· involves the patient and his family in providing care.
When developing a plan of care, the nurse may use the appropriate standard of nursing intervention as a guide.
Standard (standard care plan) is a list of activities that provide quality patient care for this problem, this is
minimum mandatory level of quality of nursing care.
Standards can be adopted both at the federal and local levels (health departments, specific medical institutions). An example of a standard of nursing practice is the OST “Protocol for the management of patients. Prevention of bedsores."
Individual care plan – a written nursing guide, which is a detailed listing of the nurse’s actions necessary to achieve nursing goals for a specific patient problem, taking into account a specific clinical situation.
Conclusion: In the third step, the nurse writes down specific nursing goals for each priority problem and selects a specific nursing intervention for each specific goal.
Stage 5 of the nursing process is continuous, occurring at each stage. The nurse evaluates the patient's health status, effectiveness of planning, nursing team, and nursing care. The outcome process provides feedback to the nurse's performance; it goes back to each stage and analyzes the reasons for success or failure. A feature of this stage in gynecology is that the assessment is partially carried out without the participation of the patient. This applies, first of all, to the nursing process during the operating period when applying general anesthesia, as well as to the early postoperative period. As in other areas of medicine, in gynecology, nursing plans can be revised or radically changed depending on the patient’s condition, the achievement or non-achievement of goals and the characteristics of the diagnostic and treatment process.
Evaluating the effectiveness of nursing interventions is a multistep process.
It is carried out:
- nurse
- patient
- relatives of the patient
- senior sister of the department
- head of department
- hospital management
Formulation for evaluating the effectiveness of nursing interventions
Short term goal: The patient noted a decrease in the PRIORITY PROBLEM after 20-30 minutes. (up to 7 days) as a result of joint actions of the doctor, nurse and patient. The goal has been achieved.
Long term goal: The patient has no PRIORITY PROBLEM by the end of days 10-14 as a result of the combined efforts of the physician, nurse, and patient. The goal has been achieved.
Nursing care Nursing support includes necessary medications. inventory, tools, etc. to achieve your goals.
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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 identify a 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 talk 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.
