(nursing diagnostics) begins with analyzing the data obtained during the examination and identifying the patient’s problems, i.e. difficulties that prevent him from achieving an optimal state of health in any given situation, including illness and the process of dying. These difficulties relate primarily to meeting the patient's basic vital needs.
In order to make the analysis of patient information constructive and targeted, it is necessary to adhere to certain principles. When studying data obtained during a nursing examination, the following is necessary:.
1. Identify needs whose satisfaction has been disrupted.
2. Identify factors contributing to or causing disease, trauma (patient’s environment, personal circumstances, etc.).
3. Find out the strengths and weak sides patient, helping to prevent or develop his problems.
4. Clearly understand whether the patient's capabilities will expand or become increasingly limited over time.
Difficulties in formulating a nursing diagnosis
The disease brings many problems into a person’s life, but not all of them become an object nursing intervention. Only those patient problems, the solution of which is within the competence of the nurse, can be formulated as nursing diagnoses. For example, vomiting (a health problem) would not be a nursing diagnosis because it cannot be corrected by methods nursing care. And the risk of aspiration from vomit is nursing diagnosis, since this problem can be prevented by the actions of the nurse.
As stated in Chapter 10 of this teaching aid, when formulating a nursing diagnosis in our country, the ICFTU is not used.
To understand how accurately the patient's problem is identified and the nursing diagnosis is correctly formulated, the following should be checked.
1. Is the problem under consideration related to a lack of self-care?
- For example, belching cannot be considered as a nursing diagnosis because the problem is not related to a self-care deficit. The patient's difficulty breathing in horizontal position associated with a deficit of self-care and can be eliminated by nursing staff. On its basis, a nursing diagnosis is formulated.
2. How clear is the formulated diagnosis to the patient?
- For example, “discomfort” is an incorrectly formulated nursing diagnosis, since it does not reflect the patient’s specific problem. “Psychological discomfort associated with having to urinate on a bedpan” is an example of a well-formulated nursing diagnosis.
3. Will the formulated diagnosis be the basis for planning? nursing actions?
- For example, “deterioration in the patient’s mood” cannot be called a nursing diagnosis, since it is not clear what nursing intervention should be; the correct formulation would be: “decreased mood associated with a deficit in habitual communication.”
Often the same problem can be caused by completely for various reasons Naturally, the nursing diagnosis will be formulated differently in each case. The intended nursing intervention will be adequate if the cause is known, since it is this that gives the correct direction to nursing care. If the patient is concerned about possible infection during parenteral administration medicines and anxiety associated with the need for outside care at home, nursing diagnoses and actions will vary. In the first case, nursing staff need to demonstratively comply with the requirements of asepsis and antisepsis, and in the second, find out which of the relatives will care for the patient and involve them in solving the problem.
4. Will the problem identified be the patient's problem?
- For example, unjustified refusal of a procedure is a problem nursing staff, not the patient; it should not be considered as a nursing diagnosis. Fear associated with the possibility of infection of the patient during parenteral administration of drugs is a correctly made nursing diagnosis, as it reflects the patient's problem.
5. Does the nursing diagnosis statement identify only one patient problem?
- For example, correcting the problem of limited mobility of a patient is associated with a whole range of tasks, the solution of which may be beyond the competence of nursing staff. Consequences must be anticipated this state and provide the patient with necessary nursing care. It would be correct to highlight a number of nursing diagnoses related to the limitation of the patient’s mobility, such as “risk of developing bedsores”, “deficit of self-care”, etc. When formulating nursing diagnoses, it should be indicated that the patient does not know, cannot, does not understand, and also that worries him. The patient’s problems may be associated not only with injury or illness, but also with the treatment being carried out, the situation in the ward, mistrust of medical personnel, family or professional relationships.
Thus, the task of nursing diagnosis is to identify all the patient’s present or possible future problems on the path to his comfortable, harmonious state; determine what is most distressing to the patient at the moment; formulate a nursing diagnosis and try, within the limits of their competence, to plan nursing care activities.
Classification of patient problems
Within nursing process consider not the disease, but possible reactions patient's response to illness and condition. These reactions may be:
- physiological (stool retention associated with adaptation to hospital conditions);
- psychological (underestimation of the severity of one’s condition; anxiety caused by a lack of information about the disease);
- spiritual (choosing new life priorities in connection with the disease; the problem of voluntary death against the background of an incurable disease; problems of relationships with relatives arising in connection with the disease);
- social (self-isolation associated with HIV infection).
The patient’s problem and the nursing diagnosis formulated on its basis may relate not only to the patient, but also to his family, the team in which he works and/or studies, and to government services, especially social assistance disabled people For example, both family members and the state may be to blame for a patient’s problem such as “social isolation associated with limited mobility.”
Depending on the time of occurrence, nursing diagnoses (patient problems) are divided into existing and potential. Existing (lack of appetite, headache and dizziness, fear, anxiety, diarrhea, lack of self-care, etc.) occur in this moment, "Here and now". Potential problems (risk of aspiration of vomit, risk of dehydration due to uncontrollable vomiting and diarrhea, high risk infections associated with surgical intervention and reduced immunity, the risk of developing bedsores, etc.) can appear at any time. Their occurrence must be anticipated and prevented through the efforts of medical personnel.
As a rule, there can be several nursing diagnoses for one disease. At arterial hypertension the most likely symptoms are headache, dizziness, anxiety, underestimation of one’s condition, lack of knowledge about the disease, and a high risk of complications. The doctor establishes the causes, outlines a plan and prescribes treatment, and the nursing staff helps the patient adapt and live with chronic disease.
During nursing diagnosis, all the patient’s problems that can be eliminated or corrected by nursing staff are taken into account. They are then ranked in order of importance and solved starting with the most important ones. When setting priorities, A. Maslow's pyramid of needs can be used. It should be remembered that if there is no emergency physical disorders, a threat to the patient’s health and life may be a violation of the satisfaction of his psychological, social, and spiritual needs.
Nursing diagnoses are classified by significance:
- to the primary ones, i.e. the main ones, in the opinion, first of all, of the patient himself, are associated with a risk to life and require emergency care;
- intermediate - not life-threatening, but contributing to the worsening of the disease and increasing the risk of complications;
- minor - not directly related to the disease or prognosis.
The patient should, whenever possible, participate in prioritizing the grouping of diagnoses. Disagreements between the patient and medical staff on this issue can be resolved through direct discussion. In case of serious violations of the patient’s psychological and emotional status, nursing staff have to take responsibility for choosing the primary diagnoses. Thus, the diagnosis of “risk of suicide” is often made without the participation of the patient, or with the participation of his relatives.
When the patient first arrived medical institution, or when his condition is unstable and changing rapidly, it is better to wait to make diagnoses until the situation is clarified and complete reliable information is collected. Premature conclusions can lead to incorrect diagnosis and, therefore, ineffective nursing care.
Everything mentioned above helps to make a correct nursing diagnosis. However, we often encounter patient problems whose causes cannot be determined. Some problems cannot be analyzed, so you just have to state the symptom: anorexia, anxiety, etc. Some diseases are caused by unfavorable life circumstances, such as job loss or loved one. Once these circumstances have been clarified in detail, nursing staff can effectively help the patient cope with their consequences.
Example. A 65-year-old patient was admitted to the cardiology department with a prolonged attack of angina. During the examination nurse finds out that he lost his wife a month ago and is now left alone, his son lives far away and rarely visits him. The patient says: “I was left alone with my grief. My heart hurts and hurts." The desire and ability of a nurse to understand and share the grief of a lonely elderly person is equally powerful drug therapy impact.
Examples of patient problem statements
For the purpose of generalizing, concretizing and consolidating the knowledge gained after reading the previous sections of the textbook, in Table. This section provides examples of the formulation of some nursing diagnoses of patients.
Patients can contact medical institution not only to identify the nature of the pathology, examination and treatment, but also to maintain and strengthen health. Supporting human health and preventing diseases occupy an increasingly important place in the activities of nursing staff and are becoming one of the most important areas of their work. When planning the nursing process in this case, it is necessary to solve problems that are associated with the need to change the patient’s attitude towards health, nutrition, habitual lifestyle, intensity of physical and psychological stress, with the consequences of the traumas experienced. For example, stressful situations, physical inactivity, overeating, smoking are regarded as risk factors for the development of a number of diseases, and primarily arterial hypertension back in at a young age complications of which lead to disability or fatalities. Nursing staff are among the main employees of health and rehabilitation schools, where the main focus of work is teaching patients to maintain a healthy lifestyle.
Table. Options for formulating patient problems and their assessment
An example of solving a problem to identify and formulate patient problems
IN surgery department Korikova E.V., 45 years old, was admitted to the hospital with a diagnosis of exacerbation chronic cholecystitis, hole-taz." Delivered by ambulance from home, accompanied by her husband. Complains of severe pain in the right hypochondrium with radiation to the back: “I have never had pain so much. I can't stand this pain. The doctor thinks it's gallbladder».
At home I took two analgin tablets, but it didn’t help, and I started feeling nauseated. Links the occurrence of pain with the intake fatty foods. She claims that over the past five years she has gained 10 kg in body weight, does not adhere to a diet, and oily and fatty foods make her feel sick and sometimes vomit. He eats regularly, sometimes eating something at night. He says that there were several similar attacks last year, the pain lasted for several hours and subsided on its own. I didn't ask for help. He usually does not use medications. Allergy history is unremarkable; he denies bad habits. Shows anxiety about hospitalization, having never been treated in a hospital before. The family has three schoolchildren. They live in a comfortable apartment.
Objectively: normal build, enhanced nutrition, body weight - 95 kg, height - 168 cm, proper weight - 66-74 kg. The skin is of normal color, there is no swelling. Temperature - 37 °C. Respiratory rate is 28 per minute, he says that he does not feel any difficulty breathing; Heart rate - 96 per minute, rhythmic pulse, good filling. She knows the situation, is agile, answers questions competently and clearly. He behaves restlessly, there are tears in his eyes, his hands are shaking.
It is necessary to analyze the collected information, identify the patient’s problems, formulate nursing diagnoses and arrange them in order of importance.
Algorithm for solving the problem.
1. Source of subjective and objective information in in this case- the patient herself.
2. The data obtained during the examination allow the nurse to identify a violation of the needs for nutrition, breathing (respiratory rate - 28 per minute, heart rate - 96 per minute), physical and psychological safety.
3. The reason for the violation of the patient’s needs and the appearance of health problems is an exacerbation of chronic cholecystitis, provoked by the intake of fatty foods.
4. No visits to the doctor, despite attacks of pain that bothered the patient for last year, non-compliance with the diet indicates that she underestimates the state of her health. The patient’s adequate response to hospitalization and information about schoolchildren give the right to hope for a successful outcome of the disease, creating a motive for maintaining a healthy lifestyle for the patient and preventing exacerbations.
5. Nursing diagnoses (patient problems).
Severe pain in the right hypochondrium with irradiation to the back, confirmed by tachycardia, tachypnea, restless behavior, hand trembling, crying, caused by exacerbation of chronic cholecystitis due to poor diet.
- The formulation reflects the patient’s individual problem and provides direction for care to reduce pain.
Anxiety about hospitalization due to lack of hospital experience.
- The wording reflects the patient’s individual problem and provides direction of care aimed at quickly adapting the patient to hospital conditions.
The risk of repeated exacerbations associated with a lack of knowledge about your disease.
- The formulation reflects the patient’s single problem, identified on the basis of the history of life and illness, and involves the inclusion of patient education measures in the nursing care plan.
Changed excessive nutrition of the patient, associated with underestimation of her own health status.
- The wording reflects one problem of the patient and gives direction to nursing care for weight loss.
The primary diagnosis in this case is strong pain. Only by reducing or eliminating painful sensations patient, you can make her a full participant in the nursing process. Then you should begin to solve less significant problems: reduce the patient’s anxiety about hospitalization and replenish her knowledge about the disease and the dangers of excessive nutrition.
Identified and formulated problems - nursing diagnoses - are recorded in accordance with the priorities in the NIB nursing care plan.
CONCLUSIONS
- begin with an analysis of the data obtained during the survey at the first stage.
- At the second stage, the patient's problems are identified and nursing diagnoses are formulated based on them. These are patient problems that prevent the achievement of optimal health, the solution of which is within the competence of the nursing staff.
- The patient’s problems can be associated not only with injury or illness, but also with the treatment process, the situation in the ward, mistrust of medical personnel, family or professional relationships.
- Nursing diagnoses can change daily and even throughout the day. Nursing diagnosis is different from medical diagnosis. The doctor determines the causes, outlines a plan and prescribes treatment, and the nursing staff helps the patient adapt and live with a chronic disease.
- The patient’s problems are divided into existing and potential based on the time of occurrence. Existing ones are taking place at the moment. The occurrence of potential ones must be anticipated and prevented through the efforts of medical personnel.
- Against the background of one disease, a patient may experience several problems and several nursing diagnoses may be formulated.
- Nursing staff must remember that if there are no emergency physical disorders, a threat to the health and life of the patient may be a violation of the satisfaction of his psychological, social, spiritual needs.
- Nursing diagnoses are classified according to importance into primary, intermediate and secondary. Whenever possible, the patient should be involved in establishing priority diagnoses. When his condition or age does not allow him to be an active participant in the nursing process, relatives or close people should be involved in setting priorities.
- When formulating a nursing diagnosis, it is advisable to indicate the reasons that led to the problem. The actions of nursing staff should primarily be aimed at eliminating these causes.
- Nursing diagnoses must be recorded in the NIB, in the nursing care plan.
Fundamentals of nursing: textbook. - M.: GEOTAR-Media, 2008. Ostrovskaya I.V., Shirokova N.V.
As soon as the nurse has begun to analyze the data obtained during the examination, the second stage of the nursing process begins - identifying the patient's problems and formulating a nursing diagnosis.
Patient problems- These are problems that exist in the patient and prevent him from achieving a state of optimal health in any given situation, including the state of illness and the process of dying. At this stage, the nurse's clinical judgment is formulated, which describes the nature of the patient's existing or potential response to the disease.
The purpose of nursing diagnosis is the development individual plan patient care so that the patient and his family can adapt to changes that have arisen due to health problems. At the beginning of this stage, the nurse identifies needs whose satisfaction in this patient is impaired. Violation of needs leads to problems for the patient.
Based on the nature of the patient’s reaction to the disease and his condition, nursing diagnoses are distinguished:
1) physiological , for example, insufficient or excessive nutrition, urinary incontinence;
2) psychological , for example, anxiety about one’s condition, lack of communication, leisure or family support;
3) spiritual, problems associated with a person’s ideas about his life values, his religion, the search for the meaning of life and death;
4) social , social isolation, conflict situation in the family, financial or domestic problems associated with becoming disabled, changing place of residence.
Depending on the time, problems are divided into existing And potential . Existing problems take place at the moment, these are problems “here and now”. For example, headache, lack of appetite, dizziness, fear, anxiety, lack of self-care, etc. Potential problems do not exist at this time, but may arise at any time. The occurrence of these problems must be anticipated and prevented through the efforts of medical personnel. For example, the risk of aspiration from vomit, the risk of infection associated with surgery and decreased immunity, the risk of developing bedsores, etc.
As a rule, several problems are simultaneously registered in a patient, so existing and potential problems can be divided into priority- those that are most significant for the patient’s life and require priority decision, and minor- the decision of which may be delayed.
The priorities are:
1) emergency conditions;
2) problems that are most painful for the patient;
3) problems that can lead to a deterioration in the patient’s condition or the development of complications;
4) problems whose solution leads to the simultaneous solution of other existing problems;
5) problems that limit the patient’s ability to self-care.
There should be few priority nursing diagnoses (no more than 2-3).
Diagnosis is designed to determine the problems the patient is experiencing and the factors contributing to or causing these problems.
Once the information is collected, it should be analyzed to determine the patient's overt and latent unmet care needs. It is necessary to determine the patient's ability to provide self-care, home care, or the need for nursing intervention. For this, the nurse needs a certain level professional knowledge, ability to formulate a nursing diagnosis.
Nursing diagnosis- this is the clinical judgment of the nurse, which describes the nature of the patient’s existing or potential response to the disease and his condition (problems), indicating the reasons for such a reaction, and which the nurse can independently prevent or resolve.
Priority issue : headache in the occipital region.
Nursing diagnosis: headache in the occipital region due to high blood pressure.
Short term goal: The patient will experience less headache after 4 days of treatment.
Long term goal: The patient will be headache-free at the time of discharge.
| Plan | Motivation |
| Independent interventions 1. Create physical and mental peace. | To reduce the effect of irritants on the central nervous system |
| 2. Provide the basic version of a standard diet with a salt limit of up to 5 g/day. | To lower blood pressure |
| 3. Provide an elevated position in bed. | To reduce blood flow to the brain and heart. |
| 4. Conduct conversations with the patient: about eliminating risk factors ( overweight, dieting, elimination bad habits), about the importance of systematically taking antihypertensive drugs and visiting a doctor. | To normalize blood pressure and prevent complications. |
| 5. Train the patient and his relatives in determining blood pressure and recognizing the first signs hypertensive crisis and provide first first aid during a hypertensive crisis. | |
| To detect fluid retention in the body. | |
| 7. Provide access fresh air by airing the room for 20 minutes 3 times a day. | To enrich the air with oxygen. |
| 8. Monitor the patient’s condition, appearance, the value of blood pressure. | |
| 2. Prepare the patient and accompany him to instrumental studies(ECG, EchoCG, blood pressure monitoring). | |
| Dependent Interventions 1. Ensure correct and timely intake of antihypertensive drugs (diuretics, ACE inhibitors, calcium antagonists, beta-blockers) as prescribed by a doctor. | For effective treatment. |
Priority issue : fluid retention (edema, ascites).
Nursing diagnosis: fluid retention (edema ascites) due to increased pressure in big circle blood circulation
Short term goal: the patient's swelling will decrease lower limbs and belly size by the end of the week.
Long term goal: the patient demonstrates knowledge about diet, calculating daily urine output at the time of discharge.
Nursing intervention plan
| Plan | Motivation |
| Independent interventions 1. Provide the basic version of a standard diet with salt limitation to 5 g/day and fluid (daily diuresis +400 ml). | To reduce swelling. |
| 3. Ensure that the patient is weighed once every 3 days. | To control the reduction of fluid retention in the body. |
| 4. Monitor daily diuresis and water balance | To control the dynamics of edema. |
| 5. Provide access to fresh air by ventilating the room for 20 minutes 3 times a day. | To enrich the air with oxygen |
| 6. Provide skin and mucous membrane care. | For the prevention of bedsores. |
| 7. Conduct conversations with the patient: about the need to follow a diet, constantly take medications (cardiac glycosides, diuretics, ACE inhibitors). | To prevent deterioration of the patient's condition and the occurrence of complications.. |
| 8. Train the patient and his relatives in determining blood pressure, pulse and monitoring daily diuresis and water balance. | To monitor the patient's condition and early detection complications. |
| 9. Monitor the patient’s condition, appearance, pulse, blood pressure. | For early diagnosis and timely provision of emergency care in case of complications. |
| Interdependent Interventions 1. Prepare the patient and collect biological material on laboratory test: general analysis blood, urine, biochemical analysis blood. | To diagnose the patient's condition |
| To diagnose the patient's condition. | |
| Dependent interventions 1. Ensure correct and timely intake of medications (diuretics, ACE inhibitors, calcium antagonists, beta-blockers, cardiac glycosides) as prescribed by the doctor. | For effective treatment. |
| 2. Carry out oxygen therapy 3 times a day for 30 minutes (as prescribed by a doctor) | To reduce hypoxia. |
Priority problem: shortness of breath.
Nursing diagnosis: shortness of breath due to increased pressure in the pulmonary circulation.
Short-term goal: The patient will experience decreased shortness of breath after 3 days of treatment.
Long-term goal: The patient will be free of shortness of breath at the time of discharge.
Nursing intervention plan
| Plan | Motivation |
| Independent Interventions 1. Provide a basic standard diet with salt limited to 5 g/day. and liquids up to 1 liter. | To reduce shortness of breath. |
| 2. Provide an elevated position in bed. | To reduce blood flow to the heart. |
| 3. Ensure frequent ventilation of the room. | To enrich the air with oxygen, reduce hypoxia |
| 4. Conduct conversations with the patient: about rational nutrition, the importance of systematically taking medications and visiting a doctor. | To prevent the progression of heart failure. |
| 5. Train the patient and his relatives in determining blood pressure, counting pulse, respiratory rate, and measuring daily diuresis. | For dynamic monitoring and prevention of complications. |
| 6. Monitor daily diuresis and water balance. | To correct water balance. |
| 7. Monitor the patient’s condition, appearance, blood pressure, pulse, respiratory rate. | For early diagnosis and timely provision of emergency care in case of complications. |
| Interdependent interventions 1. Prepare the patient and collect biological material for laboratory testing: general blood test, urine test, biochemical blood test. | To diagnose the patient's condition |
| 2. Prepare the patient and accompany him for instrumental studies (ECG, EchoCG). | To diagnose the patient's condition. |
| Dependent interventions 1. Ensure correct and timely intake of medications (diuretics, ACE inhibitors, calcium antagonists, beta-blockers) as prescribed by the doctor. | For effective treatment. |
| 2. Carry out oxygen therapy | To reduce hypoxia |
Physiological problems of patients:
· pain (including chronic pain) local, generalized, radiating;
· dehydration;
· taste disturbance;
· sleep disturbance (drowsiness, insomnia);
· weakness;
fatigue (intolerance physical activity);
· swallowing disorder;
· risk of aspiration;
· visual impairment;
· confusion;
· loss of consciousness;
· memory impairment;
· violation skin sensitivity;
· pathological condition skin;
violation of integrity skin;
· damage to the oral mucosa;
· increase lymph nodes;
· urinary retention;
· frequent and/or painful urination;
· urinary incontinence;
· risk of pregnancy complications;
· violation of the body diagram (impaired mobility);
· risk of consequences of immobility;
· walking disorder;
· decreased level of hygiene (lack of self-help skills);
· lack of self-care when washing, caring for body parts, physiological functions, dressing, eating, drinking.
Psycho-emotional problems of the patient:
· violation of speech communication;
· violation of self-esteem, including feelings of guilt;
· violation of personal identity;
· feeling of abandonment;
· disgust towards oneself or others;
· high level anxiety;
· fear of infecting loved ones;
· loss of control over the situation in the professional aspect and other aspects;
· powerlessness;
· ineffective mechanisms for coping with stress (fear, apathy, depression);
· loss of hope;
· feeling of helplessness;
Difficulty controlling emotions;
· lack of communication;
· distrust of medical personnel;
· fear of death;
· feeling of false shame;
· dependence on relatives, health workers and other persons;
· denial of illness;
· non-compliance with regime requirements;
Excessive concern about one's own physical health;
Excessive concern about one's appearance;
· risk of self-harm;
· reaction to a change of environment.
Social and everyday problems of patients:
· social isolation;
· restriction of rights (present and potential);
· violation of family communications, including family refusal of the patient (violation of the model family relations);
· financial difficulties, including the need for significant additional costs;
high risk of infecting others;
· violation of social communications.
All information about the patient must be transmitted to the doctor, who provides assistance to the patient, including psychological assistance.
The nurse carries out interventions, which he records in the nursing care chart. The nursing process map can be kept in the patient’s bedside table, in it the patient himself or those caring for him can write down his (his) problems, which he discusses with the sister. The nurse should write down the patient’s problems in his language to make it easier to discuss them with him in the future.
For example, elderly woman diagnosed with chronic brucellosis, arthrosis - arthritis of the shoulder joints, she constantly cries. It turns out that what worries her to the point of tears is not so much physical pain in the joints, how much impossibility due to limited movements in right hand pray to God. The nurse writes: “Cannot cross himself due to pain and limited movement in the right shoulder joint"and determines the woman’s violated needs: chronic pain in the right shoulder, limitation of movements, a feeling of helplessness, a feeling of guilt due to the inability to comply religious ceremonies in accordance with the Orthodox faith.
The map of the nursing process is passed around in a circle from one nurse on duty to another nurse (ward, duty), and each nurse who starts working again connects to the nursing process and discusses with the patient the dynamics of his problems, which have already been recorded by the previous sister. And each nurse, establishing the order of nursing interventions and rationally distributing her work time, in addition to all the patient’s real problems, writes down his priority problems, which should not be more than two or three.
Priority can be both real and potential problems.
Priority problems include 1) all emergency conditions, for example, delirium of a patient with acute liver failure, which has complicated the course viral hepatitis IN; 2) the most painful problems for the patient at the moment, for example, repeated diarrhea due to salmonellosis; 3) problems that can lead to various complications and deterioration of the patient’s condition, for example, the risk of developing intestinal perforation in the patient typhoid fever; 4) problems, the solution of which leads to the resolution of a number of other problems, for example, reducing fear of an upcoming intestinal colonoscopy improves the patient’s mood and sleep; 5) problems that limit the patient’s ability to self-care.
§ 5. Stage of planning care for an infectious patient
Nursing care plan is a detailed listing of the nurse's professional activities necessary to achieve nursing goals.
It is necessary to plan nursing care together with the patient, who must agree to all plan activities proposed by the nurse, which must be understandable to him. The nurse sets the patient up for success in recovery. She explains to him the need to set goals for nursing intervention and, together with him, determines ways to achieve them.
Target– this is the expected specific positive result nursing intervention for each of the patient's identified problems. The goal must be specific and realistic. It must be formulated in such a way that it is understandable to the patient and his relatives.
First, the nurse, with the participation of the patient or his relatives involved in caring for a seriously infectious patient, determines the priority of solving his identified problems. It determines the time frame for achieving the goal. Based on the time frame for achievement, a distinction is made between short-term (less than a week) and long-term goals (weeks, months).
Each of the goals of nursing care contains 1) execution or action, 2) characteristics of time, place, distance, 3) condition (with the help of someone, something).
For example, the priority problem of an infectious patient is suffocation. The goal is (action) to ensure sufficient oxygen supply to the patient’s body until respiratory function is restored (time) using the flow of air and liquid oxygen (condition).
Next, the nurse, based on the standards of nursing practice, chooses ways to achieve the goal and justifies them. Creating a personalized care plan requires the nurse to be flexible in applying standards of care to practice. She can supplement the plan with actions not provided for by the standard if she correctly argues her point of view.
As a result of the plan, a map of the nursing process is drawn up.
Date added: 2015-05-19 | Views: 5352 | Copyright infringement
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | 31 | | | | | | | | | | | | | | |
In the second step of the nursing process, the nurse identifies the patient's problems. This stage may also be called
nursing diagnosis of the patient's condition. This nickname formulates the clinical judgment of the nurse, which describes the nature of the patient’s existing or potential response to the disease and his condition with the desired indication probable cause such a reaction. This reaction may be due to illness, changes environment, therapeutic measures, living conditions, changes in the patient’s dynamic behavior pattern, personal circumstances.
The concept of "nursing diagnosis" first appeared in the United States in the mid-1950s. It was officially adopted and legislated in 1973. A list of nurse diagnoses is given in the reference literature. She must justify each diagnosis in relation to a specific patient.
The goal of nursing assessment is to develop an individualized plan of care so that the patient and family can adapt to changes caused by health problems. At the beginning of this stage, the nurse identifies needs whose satisfaction in this patient is impaired. Violation of needs leads to the patient developing problems, the classification of which is shown in Fig. 8.4.
All problems are divided into existing (real, actual), already present at the time of the examination, and potential (complications), the occurrence of which can be prevented provided that quality nursing care is organized.
As a rule, several problems are simultaneously registered in a patient, therefore both existing and potential problems can be divided into priority - the most significant
Problems
1
Existing Potential
Priority Secondary Priority Secondary
Physiological Psychosocial
Rice. 8.4. Determination of patient problems (nursing diagnostics)
tion)
important for the patient’s life and requiring a priority decision, and secondary - the decision of which can be delayed. The priorities are:
Problems that are most painful for the patient;
Problems that can lead to a deterioration in the patient’s condition or the development of complications;
Problems whose solution leads to the simultaneous solution of other existing problems;
Problems that limit the patient's ability to self-care.
Depending on the level of violated needs, the patient’s problems are divided into physiological, psychological, social and spiritual. However, due to her competence, a nurse is not always able to solve all types of problems, therefore in practice it is customary to divide them into physiological and psychosocial.
Physiological problems are pain, respiratory failure, high risk of suffocation, heart failure, reduced gas exchange, hyperthermia (overheating of the body), ineffective thermoregulation, disturbance (disorder) of the body diagram, chronic constipation, diarrhea, impaired tissue integrity, insufficient cleansing respiratory tract, reduced physical mobility, risk of violation of the integrity of the skin, risk of tissue infection, sensory changes (auditory, gustatory, muscular-articular, olfactory, tactile, visual).
Psychological problems there may be a lack of knowledge (about the disease, healthy way life, etc.), fear, anxiety, restlessness, apathy, depression, difficulty controlling emotions, lack of family support, communication, mistrust of medical personnel, lack of attention to the unborn child, fear of death, feelings of false shame, false guilt before loved ones due to his illness, lack of external sensations, helplessness, hopelessness. Social problems manifest themselves in social isolation, concerns about the financial situation in connection with becoming disabled, a lack of leisure time, and concerns about one’s future (employment, placement).
The presence of existing problems in patients contributes to the emergence of potential ones, which requires the nurse to constantly monitor the patient and carry out high-quality nursing measures to prevent them. Potential problems include risks:
The occurrence of bedsores, hypostatic pneumonia, the development of contractures in an immobile patient;
Violations cerebral circulation with high blood pressure;
Falls and injuries in patients with dizziness;
The occurrence of burns during a hygienic bath for a patient with sensitivity disorders;
Deterioration of the condition due to improper use of medications;
Development of dehydration in a patient with vomiting or frequent
loose stool.
After examining, identifying the patient's problems and determining priorities, the nurse moves on to the third stage of the nursing process - planning nursing care.
Planning nursing intervention
At the third stage of the nursing process, the nurse draws up a plan for nursing care for the patient with motivation for her actions. A generalized model of the care plan is presented in Fig. 8.5.
A nursing care plan is a detailed listing of the nurse's specific actions necessary to achieve nursing goals. Planning of nursing care is carried out with mandatory participation patient. The measures of the plan must be clear to the patient, and he must agree with them. First, the nurse determines the goals of the intervention and their priority.
Creating a nursing care plan
priority for solving identified problems
Setting goals:
1) short-term;
2) long-term
Choosing a way to solve a goal
Justification of the method for achieving the goal
Written care instructions
Rice. 8.5. Setting goals and planning nursing interventions
A goal is the expected specific positive result of nursing intervention for each of the patient's identified problems. The goals of care are subject to the following requirements;
Specificity, correspondence to the patient’s problem, for example, the goal “the patient will feel better” should not be formulated;
Reality, achievability - unrealistic goals should not be predicted;
Time frame for achieving the goal - there are two types of goals: short-term (less than 1 week) and long-term (weeks, months);
Formulation in terms of nursing (rather than medical) competence;
Presentation in terms understandable to the patient, his relatives, and others medical workers and service personnel.
The formulation of the goal of nursing care must indicate the action that needs to be performed, the time needed to perform the action, the place, distance, and the condition for performing the action. For example, the patient's priority problem is lack of swallowing. The goal in this case will be to ensure (action) a sufficient supply of fluid and food to the patient's body until swallowing function is restored (time) with the help of a probe (condition).
After setting a goal, the nurse makes a plan for achieving it. In doing so, she must be guided by standards of nursing practice that are designed to work in a typical situation, and not with a specific patient. Thus, when creating an individual plan of care, the nurse is required to be able to flexibly apply the standard to a real-life situation. She has the right to supplement the plan with actions not provided for by the standard if she can argue her point of view. As the plan is developed, the nurse completes the nursing process chart. You can use the form shown in table. 8.2, which allows for uniformity of completion, consistency, continuity and control over the quality of nursing care.
