What is the nursing process? The first stage of the nursing process. Provide information to the patient. Rationale
Votkinsk Medical College
Ministry of Health of the Udmurt Republic"
BY DESIGN
Nursing medical history
(Training manual for students and part-time teachers)
Specialty: 060501 “Nursing”
Compiled by: N.A. Visyashcheva
Votkinsk
Nursing medical history
The nursing medical history is filled out in black paste, in printed font (legible), data on allergies to medicinal substances is placed on the title page in red.
Before you begin the task, repeat the main directions of the work again:
There are five main components or stages in the nursing process.
At all stages of the nursing process, the necessary conditions for its implementation are:
® professional competence of a nurse, skills of observation, communication, analysis and interpretation of data obtained;
® trusting environment, sufficient time;
® confidentiality;
® participation of the mother and, if necessary, other persons;
® participation of other health professionals.
Stages of the nursing process.
Brief description of the nursing process.
Stage I – medical nursing examination: assessing the situation and identifying the patient's problems that are most effectively addressed through nursing care.
Nurse's task– provide motivated individualized care.
In this case, the nurse should evaluate the following groups of parameters:
1) subjective disorders indicated by the patient (patient complaints), paying attention to which complaints are more significant for the patient;
2) the state of the main functional systems of the patient’s body;
3) data obtained from laboratory tests and instrumental examinations carried out earlier.
Goals:
§ create an information database about the patient at the time of admission to the department.
§ identify the patient’s existing problems, highlight priority and potential problems.
§ Determine what kind of care the patient needs.
Basic actions:
§ data collection for nursing records;
§ conducting a physical examination;
§ collection of laboratory data;
§ data interpretation:
A. assessing the significance of the data;
b. formation of data groups, formulation of patient problems.
Stage II– identification of patient problems(nursing diagnosis).
When identifying patient problems, it is necessary to highlight:
§ physical(pain, cough, etc.),
§ psychological(fear of death, an abundance of non-existent complaints, etc.),
§ socio-spiritual(social environment, communication, leisure, etc.),
§ emotional(tearfulness, nervousness, etc.).
Since a patient always has several problems, the nurse must determine a system of priorities, classifying them as primary, secondary and intermediate. Priorities are a sequence of the patient's most important problems, identified to establish the order of nursing interventions; there should not be many of them - no more than 2-3.
Priority selection criteria:
· All emergency conditions, for example, acute pain in the heart, risk of pulmonary hemorrhage.
· The most painful problems for the patient at the moment, what worries him most is the most painful and important thing for him now. For example, a patient with heart disease, suffering from attacks of chest pain, headaches, swelling, shortness of breath, can point to shortness of breath as his main suffering. In this case, "dyspnea" will be a priority nursing problem.
· Problems that can lead to various complications and deterioration of the patient’s condition. For example, the risk of pressure ulcers in an immobile patient.
· Problems, the solution of which leads to the resolution of a number of other problems. For example, reducing fear of upcoming surgery improves the patient's sleep, appetite, and mood.
Stage III– planning nursing interventions.
Target: develop tactics for achieving goals, determine criteria for their implementation.
Basic actions:
§ identification of necessary measures;
§ determination of priority actions;
§ consultations;
§ writing a nursing plan.
Setting goals for nursing interventions (for each problem):
A. short term– aimed at restoring and maintaining vital functions of the body.
b. long-term– aimed at carrying out preventive measures regarding possible complications and underlying diseases, solving medical and psychological problems that arise when working with a sick person and his further rehabilitation.
Each goal includes 3 components:
· action;
· criteria (date, time, distance);
· condition (with the help of someone/something).
Requirements for setting goals of care:
· goals must be realistic (attainable).
· It is necessary to set specific deadlines for achieving each goal.
· the goals of nursing interventions should be within the nursing and not the medical competence.
· Goals should be formulated in terms of the patient, not the nurse.
Nursing care plan: This is a detailed listing of the specific actions the nurse needs to take to achieve nursing goals.
When developing a plan of care, the nurse may use the standard of nursing practice as a guide. On June 10, 1998, the Association of Nurses of Russia approved the “Standards for the practical activities of nurses.”
Stage IV– implementation of the nursing care plan.
Target: coordinate the work to provide nursing care in accordance with the agreed plan, dividing it into types:
§ independent nursing intervention– performed directly by a nurse without doctor’s orders.
§ dependent nursing intervention– the doctor’s prescriptions are carried out in strict sequence, taking into account the recommendations, and data on the implementation and the patient’s reaction to the manipulation are recorded in the patient’s individual record.
§ interdependent nursing intervention – the recommendations and prescriptions of related specialists who examined the patient are followed.
Basic actions:
§ re-evaluation of the patient’s condition;
§ review and changes to the existing nursing plan;
§ fulfillment of assigned tasks.
Related information.
Stages of the nursing process
The nursing process includes 5 sequential stages:
Stage I- nursing examination (patient examination).
Stage II- nursing diagnosis: identifying patient problems and making nursing diagnoses.
Stage III- planning the necessary assistance to the patient, aimed at meeting the identified needs and problems.
Stage IV- implementation of the nursing intervention plan.
Stage V- assessment of results (final assessment of nursing care).
All stages of the process are interconnected and together form a continuous cycle of thinking and action.
Nursing examination- this is the identification of violations of the patient's needs. It consists of collecting information about the state of his health, the patient’s personality, lifestyle and reflecting the obtained data in the nursing process chart (nursing medical history). How skillfully the nurse can position the patient for the necessary conversation, the information received will be more complete. Patient assessment is an ongoing, systematic process that requires observational and communication skills. Purpose of the assessment - identification of a person’s specific nursing care needs.
Nursing examination is independent and cannot be replaced by a medical one, as they face different tasks. The doctor conducts an examination, makes a medical diagnosis, identifies the causes of violations of the functions of organs and systems for the purpose of further treatment. Nurse's task - justification of motivation for individual care.
There are five sources of patient information:
1. The patient himself.
2. Non-medical environment of the patient: relatives, acquaintances, colleagues, neighbors in the ward.
3. Medical environment: doctors, nurses, emergency medical teams.
4. Medical documentation: outpatient card, medical history, examination statements, tests.
5. Special medical literature: care guides, nursing standards, an atlas of manipulation techniques, a list of nursing diagnoses, the Nursing Business magazine.
There are two types of information about the patient: subjective and objective, as well as additional examination
Subjective data- These are the patient’s own feelings regarding health problems. Typically, this information is collected through a survey. The nurse conducts a survey during the interview.
Goals of the conversation:
Establishing a trusting relationship with the patient
familiarization of the patient with the treatment;
development of an adequate attitude of the patient to his states of anxiety and anxiety;
Determination of the patient's expectations from the system of medical care;
Obtaining information that requires in-depth study.
First you need introduce yourself to the patient, give his name, position, state the purpose of the conversation. Then find out from the patient how to address him. This will help him feel comfortable. During the conversation, personal data is collected - full name, age, gender, place of residence, occupation, as well as the reasons for contacting a medical institution.
When examining a patient, you need to find out:
The state of his health, taking into account each of the 14 fundamental needs for W. Henderson ;
what the patient considers normal for himself in connection with each indicated need;
what kind of help the patient needs to meet each need;
how and to what extent the current state of health prevents him from self-care;
· what potential difficulties or problems can be foreseen in connection with changes in his health; previous illnesses and problems.
At subjective examination it turns out:
· data from medical history (Anamnesis morbi): the onset of the disease, its course, what it is connected with, what the patient did on his own, where he applied for help, what help was provided;
· data from life history (Anamnesis vitae): past illnesses, infectious diseases, tuberculosis, venereal diseases, injuries, operations, medical procedures, blood transfusions, patient response to past treatment and quality of nursing care provided;
· risk factors: smoking, alcohol, obesity, stressful situations, etc.;
Allergy anamnesis: to medicinal substances, food, household chemicals, etc.;
what basic needs the patient can satisfy himself, and with the satisfaction of which he needs help;
· are there any visual, hearing, memory, or sleep impairments;
· who or what is the support for the patient;
· how he himself assesses his condition, how he feels about the procedures.
Objective data the nurse receives about the patient's condition as a result of the patient's examination, observation and examination.
Upon objective examination nursing staff examines the patient according to a specific plan in compliance with a number of necessary rules. The patient is examined in diffuse daylight or bright artificial lighting. In this case, the light source should be located on the side: this way the contours of various parts of the body, rashes, scars, traces of wounds, etc. stand out more prominently.
Acquaintance With the objective condition of the patient begins with examination, then moving on to feeling (palpation), tapping (percussion), and listening (auscultation). It is recommended that all examination data be recorded in the nursing documentation.
Appearance assessment and patient behavior should be based on observations made throughout the collection process medical history and examinations. Assess the patient’s general condition (satisfactory, moderate, severe); state of consciousness (clear, sopor, stupor, coma); behavior (adequate, inappropriate). They also determine: position in bed (active, passive, forced), physique, height, weight, body temperature.
During examination conditions of the skin and mucous membranes evaluate: color (cyanosis, pallor, hyperemia, jaundice), humidity, temperature, elasticity and turgor, pathological elements, hair, nails, oral cavity and pharynx, etc. When examining the tongue, the presence of plaque and bad breath should be assessed.
Survey musculoskeletal system you can start with the question of the presence of pain in the joints, their localization, distribution, symmetry, irradiation, character and intensity. It is necessary to determine what increases or decreases the pain, how physical activity affects it. During examination, the presence of deformities of the skeleton, joints, and limited mobility is determined. If mobility in a joint is limited, it is necessary to find out which movements are impaired and to what extent: can the patient walk, stand, sit, bend, stand up, dress, wash freely. Limited mobility leads to limited self-care. Such patients are at risk of developing bedsores and infection and therefore require increased attention from nursing staff.
During examination respiratory system it is necessary to pay attention to changes in voice, frequency, depth, rhythm and type of breathing, chest excursion, assess the nature of shortness of breath, and physical activity; hemoptysis, chest pain, shortness of breath.
During examination of cardio-vascular system pulse and blood pressure are determined. Symmetry, rhythm, frequency, filling, tension, and pulse deficit are assessed. When complaining of pain in the heart area, the nature, localization, irradiation, duration of pain, and how it is relieved are determined. A characteristic sign of cardiovascular pathology is edema. It is also necessary to pay attention to dizziness and fainting. Such patient problems can cause falls and injuries.
When assessing the condition gastrointestinal tract attention should be paid to dysphagia, heartburn, loss of appetite, nausea, vomiting, belching and other dyspeptic disorders. From the conversation and examination, you can get information about bleeding from the rectum, constipation, diarrhea, abdominal pain, flatulence, jaundice associated with the pathology of the liver and gallbladder. It is necessary to evaluate appetite, the nature and frequency of stool, and the color of stool.
When assessing urinary system pay attention to the nature and frequency of urination, urine color, transparency, urinary incontinence. Urinary and fecal incontinence are risk factors for the development of bedsores, a psychological and social problem of the patient.
When assessing endocrine system nursing staff should pay attention to the nature of hair growth, the distribution of subcutaneous fat, a visible enlargement of the thyroid gland. Often, violations of the endocrine system entail psychological discomfort associated with changes in appearance.
During examination nervous system find out whether the patient had loss of consciousness or convulsions. When determining the nature of sleep, it is necessary to pay attention to its duration and the nature of falling asleep. Sleep may be superficial and restless. It is important to know whether the patient uses sleeping pills and which ones.
Presence of tremor, gait disturbances suggest a risk of injury and are aimed at solving the problem of patient safety during a hospital stay.
During examinationreproductive system among women find out the age of onset of the first menses, regularity, duration, frequency, amount of discharge, date of last menstruation, premenstrual syndrome, effect of menstruation on general well-being. Since what years has she been sexually active, how many pregnancies, childbirth, miscarriages, abortions, methods of contraception. In a middle-aged woman, it should be ascertained whether and when they stopped menstruating, whether the cessation was accompanied by any symptoms.
After completing the survey you should ask the patient if he has any questions. At the end, it is necessary to explain to the patient what awaits him next, to introduce him to the daily routine, employees, premises, neighbors in the ward, to give a reminder of his rights and obligations.
Upon completion of the examination nursing staff draw conclusions and record them in nursing documentation. Subsequently, daily, throughout the patient's stay in the hospital, it is recommended to display the dynamics of the patient's condition in the observation diary.
Laboratory and instrumental studies are classified as additional methods.
The patient himself is the source subjective, so objective information.
Monitoring the patient's condition. The activities of a nurse include monitoring all changes in the patient's condition, their timely selection, assessment, reporting to the doctor about these changes, and providing assistance.
After the assessment of the patient's health status, the nurse should formulate the patient's problems or conduct a nursing diagnosis using the nursing practice classifier.
The end result of the first stage nursing process is to document the information received and create a database of the patient. The collected data is recorded in the nursing medical record. Nursing history- a legal document of the independent activity of a nurse within her competence. Purpose of nursing history- monitoring the nurse’s implementation of the care plan and doctor’s recommendations, analyzing the quality of nursing care and assessing the professionalism of the nurse.
To organize a systematic approach to the implementation of the professional activities of a nurse aimed at restoring health and improving the patient’s quality of life, taking into account his needs and emerging problems, an entire science-based care technology was developed. It was called the "nursing process".
What are the main goals of this process?
The main goal of the nurse's systematic approach is to support the patient, restoring his ability to meet the basic needs of the body. In general, her work is similar to the medical process. In the same way, she first listens to the patient’s complaints, conducts an examination, the necessary laboratory and instrumental studies to establish an accurate diagnosis, on the basis of which a treatment algorithm is then selected and further recommendations are developed.
The nursing process in this case makes the nurse an indispensable specialist, who must also be distinguished by kindness, sensitivity, and attentive attitude towards the patient, and strive to significantly improve his psychological state. Properly organized communication between a medical professional and patients helps to prevent or mitigate possible deviations and adjust subsequent treatment methods.
Main stages
The nurse's action plan includes the following steps in the nursing process:
- patient examination;
- assessment of his condition;
- planning nursing interventions;
- execution of their plan;
- assessment of their effectiveness.
Data Inspection and Interpretation
The first stage is a survey necessary to obtain objective data. It includes the patient’s complaints, medical history, examination (measurement of body weight, height, temperature, pulse, blood pressure, etc.), laboratory and instrumental studies. Establishing psychological contact between the patient and the nurse at the time of examination is very important, since trust in her allows you to convince the patient to give a sufficient amount of necessary information to assist him. A haphazard survey will be incomplete and scattered. The second stage is aimed at interpreting the data obtained, identifying the patient’s violated needs and his problems.
Care planning
Planning nursing interventions involves setting goals for further patient care. They can be short-term or long-term. The first goals are completed in a short period of time, usually up to two weeks. Accordingly, longer-term ones are aimed at preventing complications, preventing relapses of diseases, rehabilitation and social adaptation.
In the process of a systems approach, types of interventions are determined, which can be dependent, independent, interdependent. Their methods are selected, and the patient’s violated needs are taken into account.
Implementation of the plan
Patient care consists of providing daily assistance in his daily life, proactive care, performing technical manipulations, teaching and counseling the patient and his family members, providing psychological support, and implementing preventive measures to prevent complications.
Process efficiency assessment
The final stage is expressed in assessing the patient’s reaction to the nurse’s care, the results obtained, analyzing the quality of care provided and summing up the results. The nursing process may be revised if any interfering factors are identified. The main thing is to achieve high quality care. A systematic evaluation process allows you to compare the achieved results with the expected ones.
Aspects of nursing processes
The nursing process in therapy largely depends on the type of disease. The initial examination, identification of risk factors and characteristic symptoms is carried out by the nurse, taking into account the patient’s illness. The systematic approach to diagnosing diseases of the digestive, respiratory, circulatory and other systems is different. That is why recently in the world of new technologies, including in medicine, the requirements for the quality of education and training of nurses have increased. They must fully know the definitions, causes, clinical picture, risk factors, treatment methods, rehabilitation and prevention of the most common diseases of internal organs.
Benefits of a systems approach
The systemic nursing process has a number of advantages. First of all, this is a personal approach to the patient, a holistic consideration of the patient’s personal, clinical and social needs, his participation in the planning and process of care. This is also constant monitoring of the patient’s health status, providing the necessary nursing intervention, changing his methods if necessary. And the assessment of the care received creates all the conditions for the possibility of continuous improvement of the quality of patient care, which is achieved through an analysis of existing and identified problems in the provision of medical services, the development of new forms of organization and improvement of corporate culture. Nursing care is indispensable if long-term or constant monitoring of a disabled or elderly person is necessary. This is the most ideal solution to the problem, because a nurse combines such qualities as knowledge of medicine, skills in necessary treatment procedures, and patience, which help not only to care for and treat a person, but also to instill in him confidence and independence during the rehabilitation period.
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 that are obtained as a result of observations and examinations conducted by a nurse.
Second phase - nursing diagnosis.
This is the formation of real or possible future deviations from a comfortable state and the formulation of a priority problem / nursing diagnosis /.
Target stage - the definition of the patient's problems, the establishment of factors causing the development of these problems, the identification of those qualities of the patient that can help prevent or resolve his problems.
From the point of view of a nurse, problems appear when a patient, due to certain reasons (illness, injury, age, unfavorable environment), has 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 resources.
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 with the help of crutches 7 meters 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:
Coordinating the work of the nursing team
Provides continuity in nursing care
· Helps maintain communication with other health professionals,
reduces the risk of incompetent or careless care,
Provides for the participation of the patient and his family in the provision of 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.
The final fifth stage of the nursing process- assessing the effectiveness of care and correcting it if necessary. Stage goals:
- assess the patient's reactions to nursing care;
- evaluate the results obtained and summarize;
- issue a discharge summary;
- analyze the quality of assistance provided.
Care assessments are carried out not only on the day the patient is discharged from the hospital, but constantly, at every meeting: during rounds with the doctor, during procedures, in the corridor, dining room, etc. The patient's condition changes daily and even several times a day, which is not always caused by the nature of the disease and treatment. This may be due to relationships with roommates, medical staff, attitude towards procedures, news from home or from relatives. Monitoring the patient is also an action of nursing staff. It is necessary to notice the slightest changes in the condition or behavior of patients, considering behavior as one of the main evaluation criteria. Each time there is contact with a patient, the nursing process occurs anew. For example, after surgery in the morning, a patient was unable to independently change his body position, and after 3 hours the nurse noticed that he was turning over without outside help. This is both new information about the patient and an evaluation criterion. Changes in the patient’s behavior and condition, reflecting positive dynamics, are another victory for the medical staff. Unfortunately, sometimes treatment and care is ineffective. For example, after completing the planned measures to reduce the temperature, a patient again complains of chills after receiving a drip infusion.
Not always and not all problems are recorded; more often (if they do not affect the course of the disease or prognosis) they are simply noted by the nursing staff and verbally passed on to the shift. Conversely, ICU patient assessment and recording are performed in our clinics every half hour to hour. If a patient requires increased attention from the staff, the criteria for assessing his condition are entered into the duty notebook, discussed at the beginning of the working day at “five-minute meetings” and in the evening when the shift is handed over.
To conduct the final stage of the nursing process efficiently, you need to: know what aspect you want to evaluate; have sources of information important for the assessment; clarify the evaluation criteria - the expected results that nursing staff want to achieve together with the patient.
Rice. Step Five of the Nursing Process
Assessment aspects
Evaluation stage is a mental activity. Based on the use of certain evaluation criteria, nursing staff will have to compare the existing results of care with the desired ones: evaluate the patient’s reaction and, on this basis, draw a conclusion about the results obtained and the quality of care. For an objective assessment of the degree of success of care, it is necessary:
- clarify the goal and expected result in the patient’s behavior or reaction to the disease or his condition;
- assess whether the patient has the desired response or behavior;
- compare the evaluation criteria with the existing reaction or behavior;
- determine the degree of consistency between goals and the patient's response.
Criteria for evaluation
The evaluation criteria may be the patient’s words or behavior, objective research data, information received from roommates or relatives. For example, for edema, the assessment criteria may be weight and fluid balance; when identifying the level of pain, pulse, position in bed, behavior, verbal and nonverbal information, and digital pain rating scales (if used) (Table 15-1).
If the set goals are achieved, the patient’s problem is solved, the nursing staff must make an appropriate entry in the medical history, put the date the problem was resolved and their signature.
Sometimes the patient’s opinion about the actions taken plays a decisive role at the assessment stage.
Sources of assessment
The source of evaluation is not only the patient. Nursing staff takes into account the opinions of relatives, roommates, and all team members involved in the treatment and care of the patient.
The effectiveness of all care is assessed when the patient is discharged, transferred to another health care facility, or to the pathology department in the event of death.
If necessary, the nursing action plan is revised or interrupted. When a goal is partially or completely not achieved, the reasons for failure should be analyzed, which may include:
- lack of psychological contact between staff and patients;
- language problems in communicating with the patient and relatives;
- incomplete or inaccurate information collected at the time of admission of the patient to the hospital or later;
- erroneous interpretation of problems;
- unrealistic goals;
- wrong ways to achieve goals, lack of sufficient experience and professionalism in the implementation of specific care activities;
- insufficient or excessive participation of the patient and relatives in the process of care;
- reluctance to ask colleagues for help when necessary.
Actions of nursing staff in the absence of the effect of care
If there is no effect, the nursing process starts all over again in the same sequence.
Evaluation allows staff not only to find out the patient's response to the care provided, but also to identify the strengths and weaknesses of their professional activities.
Registration of discharge summary
By the end of a patient's time in hospital, short-term care goals have often already been achieved. In preparation for discharge, a discharge summary is drawn up, the patient is transferred under the supervision of a district nurse, who will continue care to achieve long-term goals related to rehabilitation and relapse prevention. The epicrisis provides for a reflection of all the care received by the patient in the health care facility. It records:
- problems present in the patient on the day of admission;
- problems that appeared during your stay in the department;
- the patient's reaction to the care provided;
- problems remaining upon discharge;
- patient’s opinion about the quality of care provided. Nursing staff who continue to care for the patient after discharge have the right to reconsider the planned activities in order to quickly adapt the patient to home conditions.
A sample of filling out the epicrisis is presented in the NIB at the end of the chapter. Rules for issuing a discharge summary in the nursing care card for the patient Korikova E.V. are given in the NIB at the end of the section.
Table. Examples of problems and criteria for assessing goal achievement
Table. Comparison of patient's goal and response to care provided
Table. An example of what a nurse should do if the goal of care is not achieved.
Is there a future for nursing process?
The problems that a health worker solves in helping patients are themselves fraught with tension, anguish and worries. If we add to this the mistakes, blunders, human weaknesses, trials that everyday life exposes, then the congestion of medical workers, their intense rhythm of life, sometimes not maintaining the load, will become clear. This can be avoided by a good organization of work, which is largely due to the introduction of modern nursing technology - the nursing process.
Many people think that the nursing process is a formalism, “extra paperwork” that there is no time to fill out. But the fact is that behind this is the patient, who in a state of law should be guaranteed effective, high-quality and safe medical care, including nursing.
A nurse is an equal member of the medical team, necessary for both a great surgeon and a brilliant therapist. In a number of healthcare facilities that are trying to improve nursing technologies, both understanding and support from doctors are noted, and without this, innovations are impossible.
In practical health care institutions, “Nursing Patient Observation Cards” began to be kept. These examples show that it is not applied to everyone, more often than not to a geriatric, doomed, seriously ill patient. In practice, it is compact, designed for a professional and not so voluminous compared to the example you saw in this manual. The form of maintaining such a document is arbitrary: the map cannot be standard. Its value lies in the reflection of the work of this team of nurses, taking into account its characteristics and the specifics of the patients. Recording each action of a nurse to care for a specific patient in a nursing observation chart makes it possible to determine the volume and quality of care provided, compare the care provided with standards, and blame or justify the nurse if necessary. The absence of such a document showing the participation of nursing staff in the process of managing a particular patient in practical healthcare negates their responsibility for their actions.
Representatives of healthcare facilities that have introduced an experimental “Nursing Patient Monitoring Card” say that this is a chance to improve the quality of nursing care, evaluate participation and show “your face” in the treatment process, and solve a number of problems (primarily in favor of the nurse and the patient).
Health is a lot of work. Illness is always a big and difficult “adventure”. Monitoring its development, thoroughly studying the patient’s problems, and joyfully solving complex problems during treatment are the most important goals of a nurse’s work.
The introduction of new nursing technologies into the practice of medical institutions, which involve a creative approach, can ensure the further growth and development of nursing as a science, have an effective impact on the quality of medical care, and increase the importance and prestige of the profession in the healthcare system.
conclusions
- The fifth, final stage of the nursing process is assessing the effectiveness of care and correcting it if necessary.
- The source of assessment is not only the patient, nursing staff takes into account the opinions of relatives, roommates, and all team members involved in the treatment and care of the patient.
- The patient’s words or behavior, objective research data, information received from roommates or relatives can be used as evaluation criteria. Patient behavior is one of the main criteria for assessing care.
- Assessment allows nursing staff not only to assess the patient's response to the care provided, but also to identify the strengths and weaknesses of their professional performance.
- An assessment of the effectiveness of all care is carried out by nursing staff when a patient is discharged, transferred to another health care facility, or to the pathology department in case of death. Information obtained at the time of final assessment should be reviewed and recorded in the nursing discharge summary. Here, not only the amount of nursing care provided and the patient’s response to care is noted, but also problems that need to be addressed after the patient is discharged from the health care facility.
- Nursing staff who continue care after discharge have the right to review planned activities to quickly adapt the patient to home conditions.
- Maintaining a “Nursing Patient Observation Card” in practical healthcare is a chance to improve the quality of nursing care and evaluate the role of nursing staff in treating patients.
Fundamentals of nursing: textbook. - M.: GEOTAR-Media, 2008. Ostrovskaya I.V., Shirokova N.V.
