home Thyroid 5 stages of the nursing process in brief. Brief description of the stages of the nursing process. Planning the nursing process

5 stages of the nursing process in brief. Brief description of the stages of the nursing process. Planning the nursing process

13. The concept of the nursing process, its purpose and ways to achieve it

Currently, the nursing process is the core of nursing education and creates the theoretical scientific basis for nursing care in Russia.

Nursing process is a scientific method of nursing practice, a systematic way of identifying the patient and nurse situation and the problems that arise in that situation in order to implement a plan of care that is acceptable to both parties.

The nursing process is one of the basic and integral concepts of modern models of nursing.

The goal of the nursing process is maintaining and restoring the patient’s independence in meeting the basic needs of the body.

Achieving the goal of the nursing process carried out by solving the following tasks:

1) creating a patient information database;

2) determining the patient's needs for nursing care;

3) designation of priorities in nursing care, their priority;

4) drawing up a care plan, mobilizing the necessary resources and implementing the plan, that is, providing nursing care directly and indirectly;

5) assessing the effectiveness of the patient care process and achieving the goals of care.

The nursing process brings a new understanding of the role of the nurse in practical healthcare, requiring from her not only technical training, but also the ability to be creative in caring for patients, the ability to individualize and systematize care. Specifically, it involves the use of scientific methods to determine the health needs of the patient, family or society, and on this basis the selection of those that can be most effectively met through nursing care.

The nursing process is a dynamic, cyclical process. Information obtained from assessing the results of care should form the basis for the necessary changes, subsequent interventions, and actions of the nurse.

14. Stages of the nursing process, their relationship and the content of each stage

I stage– nursing assessment or assessment of the situation to determine the patient's needs and the resources needed for nursing care.

II stage– nursing diagnosis, identification of patient problems or nursing diagnoses. Nursing diagnosis- this is the patient’s health status (current and potential), established as a result of a nursing examination and requiring intervention by the nurse.

Stage III– planning the necessary care for the patient.

Planning refers to the process of forming goals (i.e., desired outcomes of care) and the nursing interventions necessary to achieve these goals.

IV stage– implementation (implementation of the nursing intervention (care) plan).

V stage– outcome assessment (summary assessment of nursing care). Evaluating the effectiveness of the care provided and adjusting it if necessary.

Documentation of the nursing process is carried out in the nursing record of monitoring the patient's health status, an integral part of which is the nursing care plan.

15. Principles of record keeping

1) clarity in the choice of words and in the entries themselves;

2) brief and unambiguous presentation of information;

3) coverage of all basic information;

4) use only generally accepted abbreviations.

Each entry must be preceded by a date and time, and the entry must be followed by the signature of the nurse writing the report.

1. Describe the patient's problems in his own words. This will help you discuss care issues with him and help him better understand the care plan.

2. Call goals what you want to achieve together with the patient. Be able to formulate goals, for example: the patient will have no (or reduced) unpleasant symptoms (indicate which ones), then indicate the period within which, in your opinion, a change in health status will occur.

3. Create individual patient care plans based on standard care plans. This will reduce plan writing time and define a scientific approach to nursing planning.

4. Keep the care plan in a place convenient for you, the patient and everyone involved in the nursing process, and then any member of the team (shift) can use it.

5. Mark the deadline (date, deadline, minutes) for the implementation of the plan, indicate that assistance was provided in accordance with the plan (do not duplicate entries, save time). Sign the specific section of the plan and include any additional information that was not planned but was required. Correct the plan.

6. Involve the patient in keeping records related to self-care or, for example, taking into account the water balance of daily urine output.

7. Train everyone involved in care (relatives, support staff) to perform certain elements of care and record them.

The period of implementation of the nursing process is quite long, so the following problems related to documentation may arise:

1) the impossibility of abandoning old methods of record keeping;

2) duplication of documentation;

3) the care plan should not distract from the main thing - “providing assistance.” To avoid this, it is important to view documentation as a natural progression of the continuum of care;

4) documentation reflects the ideology of its developers and depends on the nursing model, therefore it is subject to change.

16. Methods of nursing interventions

Nursing care is planned on the basis of disruption to the patient's needs, and not on the basis of a medical diagnosis, i.e. disease.

Nursing interventions can also be ways to meet needs.

It is suggested to use the following methods:

1) provision of first aid;

2) fulfillment of medical prescriptions;

3) creating comfortable conditions for the patient in order to satisfy his basic needs;

4) providing psychological support and assistance to the patient and his family;

5) performing technical manipulations and procedures;

6) implementation of measures to prevent complications and promote health;

7) organizing training in conducting conversations and counseling the patient and his family members. Planning of necessary care is carried out on the basis of the classification of nursing actions according to the INCP (International Classification of Nursing Practice).

There are three types of nursing interventions:

1) dependent;

2) independent;

1) obtain a clear understanding of the patient before care planning begins;

2) try to determine what is normal for the patient, how he sees his normal state of health and what help he can provide himself;

3) identify the patient's unmet care needs;

4) establish effective communication with the patient and involve him in cooperation;

5) discuss care needs and expected care outcomes with the patient;

6) determine the patient’s degree of independence in care (independent, partially dependent, completely dependent, with the help of whom);

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 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 regimen;

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 the intake of 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.

III. Main stages of the procurement process for industrial goods

IV. ORGANIZATION OF THE EDUCATIONAL PROCESS. 4.1. The institution carries out the educational process in accordance with the levels of general education programs at the three levels of general education and implements

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

Examination.
Problem identification (diagnosis).
Care planning.
Provide care as planned.
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 functioning 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:

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

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

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

The assessment is carried out by the nurse continuously, with a certain frequency, which depends on the patient’s condition and the nature of the problem.

For example, One patient will be assessed at the beginning and end of the shift, and another will be assessed every hour.

Assessment aspects:

§ Achieving goals regarding patient problems.

§ The emergence of new problems that require the attention of the nurse.

The fifth stage is the most difficult, since it requires the nurse to think analytically: the nurse compares the existing results with the desired ones, using evaluation criteria . The patient’s words and/or behavior, objective research data, and information from the patient’s environment can be used as evaluation criteria.

For example, in case of dehydration, water balance can be used as an evaluation criterion, and when determining the level of pain, the corresponding digital scales can be used.

If the problem is resolved, the nurse should reasonably document this in the nursing record.

If the goal was not achieved, the reasons for the failure should be determined and the necessary adjustments should be made to the nursing care plan. In search of an error, it is necessary to once again analyze all the sister’s actions step by step.

For example, Having casually collected information about the patient at the first stage and started training him on self-administration of insulin, the nurse unexpectedly found out that the patient suffers from a visual impairment and does not see the division on the syringe, and therefore cannot control the dose of insulin. The nurse should make a correction: advise the patient to purchase an insulin syringe pen, a syringe with an attached magnifying glass, or teach this to loved ones.

Example No. 1. A 65-year-old patient experiences involuntary urine leakage drop by drop, occasionally in portions without the urge to urinate. He is a widower, lives with his son and daughter-in-law in a 2-room apartment with all amenities. He has one grandson, 15 years old, who loves his grandfather dearly. The patient is worried about returning home because he does not know how the family will react to his problem. The son and grandson visit their father every day, but he refuses to meet with them; he lies with his face turned to the wall all day and sleeps poorly.

The patient suffers from meeting the needs: EXCITING, BEING HEALTHY, BEING CLEAN, AVOIDING DANGER, COMMUNICATING, WORK. In this regard, the following problems can be identified:

1) urinary incontinence;

2) anxiety about one’s condition;

3) sleep disturbance;

4) refusal to meet with loved ones;

5) a high risk of violating the integrity of the skin and the appearance of diaper rash in the groin area.

PRIORITY PATIENT PROBLEM: urinary incontinence. Based on it, the nurse sets goals in working with the patient.

Short term goals:

a) by the end of the week the patient realizes that with appropriate treatment this painful phenomenon will decrease or go away,

6) by the end of the week, the patient realizes that with appropriate organization of care, this phenomenon will not create discomfort for others.

Long-term goals: The patient will be psychologically prepared for family life at the time of discharge.

1. The nurse will provide isolation for the patient (separate room, screen).

2. The nurse will talk with the patient about his problem every day for 5-10 minutes.

3. The nurse will advise the client not to limit fluid intake.

4. The nurse will ensure that a male urinal bag is always used at night and a removable urinal bag is used during the day.

5. The nurse will ensure that the urine bag is disinfected daily and treated with potassium permanganate solution, 1% hydrochloric acid solution, or 0.5% clarified bleach solution to eliminate the ammonia odor.

6. The nurse will monitor bed hygiene: the mattress will be covered with oilcloth, bed linen and underwear will be changed after each case of urination in the bed.

7. The nurse will ensure hygiene of the skin of the groin area (washing and treating with Vaseline or baby cream at least three times a day).

8. The nurse will ensure the room is ventilated at least 4 times a day for 20 minutes and the use of deodorizers.

9. The nurse will provide wet cleaning of the room at least 2 times a day.

10. The nurse will observe the color, clarity, and odor of the urine.

11. The nurse will teach the patient's relatives about home care.

12. The nurse will provide sufficient time to discuss the patient's problems daily, focusing his attention on modern incontinence care products (removable urinals, absorbent panties and diapers with a deodorizing effect, means for preventing diaper rash). The nurse will familiarize the patient with the literature on this issue.

13. The nurse will talk with relatives about the need for psychological support for the patient.

14. The nurse will encourage the patient's family to show attention to him without personal contact for several days (transfers, notes, flowers, souvenirs).

15. The nurse will encourage relatives to visit and inform them of appropriate behavior.

16. The nurse will provide sedatives and tranquilizers as prescribed by the doctor.

17. The nurse will provide an introduction to the client who has urinary incontinence and is adjusted to his condition.

Questions for self-study

1. The essence of the third stage of the nursing process.

2. List the main components of the goal.

3. List the requirements for setting goals:

4. Explain how to properly plan nursing interventions.

5. The essence of the fourth stage of the nursing process.

6. List and describe the categories of nursing interventions:

§ independent,

§ dependent,

§ interdependent.

7. The essence of the fifth stage of the nursing process.

8. List the sources and criteria for evaluating nursing care.

Literature

Main sources:

Textbooks

1. Mukhina S.A. Tarnovskaya I.I. Theoretical foundations of nursing: Textbook. – 2nd ed., rev. and additional – M.: GEOTAR – Media, 2008.

2. Mukhina S. A., Tarnovskaya I. I. “Practical guide to the subject “Fundamentals of Nursing” Moscow Publishing Group “Geotar-Media” 2008.

3. Obukhovets T.P., Sklyarova T.A., Chernova O.V. Fundamentals of Nursing. – Rostov e/d.: Phoenix, 2002. – (Medicine for you).

4. Fundamentals of nursing: introduction to the subject, nursing process. ∕Compiled by S.E. Khvoshcheva. – M.: State Educational Institution VUNMC for Continuing Medical and Pharmaceutical Education, 2001.

5. Ostrovskaya I.V., Shirokova N.V. Fundamentals of Nursing: Textbook. – M.: GEOTAR – Media, 2008.

Additional sources:

6. Nursing process: Proc. manual: Transl. from English ∕Under general ed. Prof. G.M. Perfileva. – M.: GEOTAR-MED, 2001.

7. Shpirina A.I., Konopleva E.L., Evstafieva O.N. Nursing process, universal human needs for health and illness ∕Uch. A manual for teachers and students. M.; VUNMC 2002.

Fifth stage of the nursing process

Parameter name	Meaning
Article topic:	Fifth stage of the nursing process
Rubric (thematic category)	Medicine

The final fifth stage of the nursing process- assessment of the effectiveness of care and its correction if it is extremely important. 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 should be determined by 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 basic assessment 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 are 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, assessment and recording of critical care patient performance indicators is carried out in our clinics every half hour or hour. If a patient requires increased attention from the staff, the criteria for assessing his condition are entered into the duty notebook and discussed at the beginning of the working day at “five-minute” meetings and in the evening when the shift is turned over. For the quality of the final stage of the nursing process, it is extremely important: to know which aspect you want to evaluate; have sources of information important for assessment; clarify the evaluation criteria - the expected results that nursing staff want to achieve together with the patient.

Rice. Fifth stage 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 success rate of care, it is extremely important: - 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 reaction or behavior; - compare the assessment 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 are the patient’s words or behavior, objective research data, information received from roommates or relatives. For example, in case of edema, the assessment criteria may be weight and water balance; when identifying the level of pain - pulse, position in bed, behavior, verbal and non-verbal information and digital pain rating scales (if used). If the set goals are achieved, the problem the patient is resolved, 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 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 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 it is extremely important, the nursing action plan is revised or interrupted. When the goal is partially or completely not achieved, the reasons for failure should be analyzed, including: - lack of psychological contact between staff and patient; - language problems in communicating with the patient and relatives; - incomplete or inaccurate information collected at the time of patient admission to the hospital or later; - erroneous interpretation of problems; - unrealistic goals; - incorrect ways to achieve goals, lack of sufficient experience and professionalism in performing specific care activities; - insufficient or excessive participation of the patient and relatives in the care process; - reluctance to ask for help from colleagues when it is extremely important.

Actions of nursing staff in the absence of the effect of care

If there is no effect, the nursing process begins again in the same sequence. Assessment allows staff not only to know the patient's response to the care provided, but also to identify strengths and weaknesses in their professional performance.

Registration of discharge summary

At the end of a patient's hospital stay, short-term care goals have often already been achieved. In preparation for discharge, a discharge summary is prepared, the patient is transferred under the supervision of a local nurse, who will continue care to address 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 will continue to care for the patient after discharge have the right to revise the planned activities in order to quickly adapt the patient to home conditions.

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 healthcare professional solves when caring for patients are themselves fraught with tension, anguish and anxiety. If we add to this errors, blunders, human weaknesses, and the trials that everyday life exposes, then the overload of medical workers, their intense rhythm of life, and sometimes not being able to withstand the load will become clear. This can be avoided by good organization of work, which is possible largely thanks 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 legal state must be guaranteed effective, high-quality and safe medical care, incl. and sisterhood. 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 innovation is impossible. In practical healthcare institutions, they began to maintain “Patient Nursing Observation Cards”. 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 does not have to 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 in caring 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 it is extremely important. 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 “Patient Nursing Observation 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 it is extremely important. - 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 can be used as evaluation criteria, objective research data, information received from roommates or relatives. Patient behavior is one of the basic 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 work. - The effectiveness of all care is assessed by nursing staff when the 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.

Literature:

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

The fifth stage of the nursing process - concept and types. Classification and features of the category "Fifth stage of the nursing process" 2017, 2018.