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• Subjective examination
• Objective examination
• conclusions

The first step in the nursing process is the examination of the patient.

Each stage of the nursing process is closely interconnected with the others and serves its main task - to help the patient in solving his health problems.

To organize and implement quality patient care, nursing staff need to collect information about him from all possible sources. It can be obtained from the patient himself, members of his family, witnesses of the incident, the nurse herself, her colleagues. Based on the information collected, problems are identified and identified, a plan is drawn up, and the planned actions are implemented. The success of treatment largely depends on the quality of the information received.

Nursingexaminationis differentfrommedical. The goal of the doctor's activity is to make a diagnosis, identify the causes, the mechanism of the development of the disease, etc., and the goal of the nursing staff's activity is to ensure the quality of life of a sick person. To do this, first of all, it is necessary to determine the patient's problems associated with the current or potential state of his health.

Information about the patient must be complete and unambiguous. The collection of incomplete, ambiguous information leads to an incorrect assessment of the patient's needs for nursing care, and, as a result, to ineffective care and treatment. The reasons for collecting incomplete and ambiguous information about the patient may be:

inexperience and disorganization of nursing staff;

the inability of nursing staff to collect specific information about a particular area;

the nurse's tendency to jump to conclusions, etc.

Sources of information when examining a patient

Nursing staff obtain information about the patient from five main sources.

1) from the patient himself;

2) relatives, acquaintances, neighbors in the ward, random people, witnesses of what happened;

3) doctors, nurses, members of the ambulance team, nurses;

4) from medical records: inpatient card, outpatient card, extracts from the case histories of previous hospitalizations, examination data, etc.;

5) from special medical literature: care guides, standards for nursing manipulations, professional journals, textbooks, etc.

Based on the data obtained, it is possible to judge the patient's health status, risk factors, characteristics of the disease, and the need to provide nursing care to the patient.

A patient- the main source of subjective and objective information about yourself. In cases where he is incapacitated, in a comatose state, or is an infant or child, his relatives may be the main source of data. Sometimes they alone know about the peculiarities of the patient's condition before the illness and during the period of the illness, about the medications he takes, allergic reactions, seizures, etc. However, do not think that this information will be exhaustive. From other sources, other data may be obtained, possibly even contradicting the data of the main ones. For example, a spouse may report a tense family situation, depression, or alcohol addiction, which the patient himself denies. Information received from family members can affect the speed and quality of care. In case of discrepancies in the data, it is necessary to try to obtain additional information from other persons.

The patient's medical environment is a source of objective information based on the patient's behavior, his response to treatment, obtained during diagnostic procedures, and communication with visitors. Each member of the medical team is a potential source of information and can report and verify data obtained from other sources.

The main medical documentation needed by nursing staff is an inpatient or outpatient card. Before proceeding with the interview of the patient, the nursing staff familiarizes themselves with such a card in detail. In the case of re-hospitalization, previous case histories are of interest, requested in case of need in the archive. This is a source of valuable data regarding the characteristics of the course of the disease, the volume and quality of nursing care provided, psychological adaptation, the patient's reactions to hospitalization, the negative consequences associated with the patient's previous stay in the hospital or seeking medical help. In the process of familiarizing the nursing staff with the history of the patient's disease, hypotheses may appear about the possible causes of his problems (work in hazardous production, aggravated heredity, family troubles).

The necessary information can also be obtained from documentation from the place of study, work, service, from medical institutions where the patient is observed or observed.

Prior to requesting documentation or interviewing a third party, the patient's or their caregiver's permission is required. Any information received is confidential and is treated as part of the patient's official medical records.

At the final stage of collecting information, nursing staff can use special medical literature on patient care.

ExiststwokindinformationOpatient: subjective and objective.

nursing process patient condition

subjectiveinformation- This is information about the patient's own feelings about health problems. For example, complaints of pain are subjective information. The patient can report the frequency of pain, its characteristics, duration, location, intensity. Subjective data include patient reports of feelings of anxiety, physical discomfort, fear, complaints of insomnia, poor appetite, lack of communication, etc.

objectiveinformation- the results of the measurements or observations made. Examples of objective information are measurements of body temperature, pulse, blood pressure, identification of rashes (rashes) on the body, etc. The collection of objective information is carried out in accordance with existing norms and standards (for example, on the Celsius scale when measuring body temperature).

Contents of the first stage of the nursing process

Subjective data obtained from the patient and his non-medical environment confirm the physiological changes expressed by objective indicators. For example, confirmation of the patient's description of pain (subjective information) - physiological changes expressed in high blood pressure, tachycardia, heavy sweating, forced position (objective information).

For a complete collection of information about the past and present state of health (history of life and anamnesis of the disease), the nursing staff conducts a conversation with the patient, studies the medical history, gets acquainted with the data of laboratory and instrumental studies.

Survey as the main method of collecting subjective information about the patient

The nursing examination usually follows the medical examination. The first step in the nursing examination of the patient is the collection of subjective information using a nursing survey (collection of primary information about objective and / or subjective facts from the words of the interviewee).

When conducting a survey, it is necessary to use specific communication skills in order to focus the patient's attention on his state of health, to help him realize the changes that are taking place or will take place in his lifestyle. A benevolent attitude towards the patient will allow him to cope with such problems as distrust of medical personnel, aggression and agitation, hearing loss, speech impairment.

Goalsholdingsurvey:

establishing a trusting relationship with the patient;

familiarization of the patient with the course of treatment;

development of an adequate attitude of the patient to the states of anxiety and anxiety;

clarification of the patient's expectations from the system of medical care;

obtaining key information requiring in-depth study.

At the beginning of the survey, you must introduce yourself to the patient, give your name, position, and state the purpose of the conversation. Then find out from the patient how to address him. This will help him feel comfortable.

Most patients, when seeking medical help, and especially when they are in a hospital, experience anxiety and anxiety. They feel defenseless, they are afraid of what lies ahead, they are afraid of what they might find, and therefore they hope for participation and care, they feel joy from the attention given. The patient must be reassured, encouraged, given the necessary explanations and advice.

During the survey, not only the nursing staff, but also the patient receives the information he needs. If contact is established, the patient will be able to ask questions of interest to him. In order to correctly answer them, it is necessary to try to understand the feelings of the patient. Particular care must be taken when patients ask for advice on a personal matter. The opportunity to talk about it with medical staff is usually more important than the answer itself.

If the interview is successful, there is an opportunity to establish a trusting relationship with the patient, involve him in formulating goals and drawing up a plan for nursing care, and resolve issues regarding the need for consultation and patient education.

The patient should be monitored during the interview. His behavior with family members, health care environment will help to understand whether the data obtained through observation are consistent with those identified during the survey. For example, in the case when the patient claims that he is not worried, but looks worried and irritable, observation will provide an opportunity to obtain the necessary additional information.

By listening to the patient and skillfully having a conversation with him, you can find out what worries him and what problems he has, what, in his opinion, became the cause of his condition, how this condition developed, and what he thinks about the possible outcome of the disease.

Everything that can be learned by collecting an anamnesis helps to form a nursing history of the patient and highlight those problems that should be given special attention.

Patient Nursing Care Card

In accordance with the State Educational Standard, the study of a patient's nursing history (NIS) has been introduced into the training program for nursing personnel in all schools and colleges of the Russian Federation. In accordance with the chosen model of nursing, each educational institution develops its own patient follow-up card or nursing history. At the end of this section (Chapter 16) is a nursing care card for the patient, which is filled out in medical schools and colleges in the Moscow region.

In the SIB, you must indicate the date of the patient's interview, and in the case of a rapid change in circumstances, the time.

The presentation of information received from the patient, as a rule, is preceded by certain information that is introductory.

Personal data (age, gender, place of residence, occupation) will allow not only to establish who the patient is, but also to get a rough idea of ​​what kind of person he is and what health problems he may have.

The way in which a patient enters a health facility or seeks help will help to understand the patient's possible motives. Patients who seek help on their own initiative are different from those who come by referral.

Source of information. It is necessary to indicate in the NIS from whom the information about the patient was received. This may be himself, his relatives, friends, members of the medical team, police officers. The necessary information can also be gleaned from the patient's documentation.

The reliability of the source is indicated if necessary.

Subjective examination

Main complaints. The main part of the NIB begins with this section. It is better to write down the words of the patient himself: "My stomach hurts, I feel very bad." Sometimes patients do not make obvious complaints, but state the purpose of hospitalization: "I was put in just for examination."

History of present illness. Here you should clearly, in chronological order, indicate the health problems that made the patient seek medical help. Information can come from the patient or his environment. Nursing staff must organize the information. It is necessary to find out when the disease began; the circumstances under which it arose, its manifestations and any self-treatment undertaken by the patient (taking drugs, enema, heating pad, mustard plasters, etc.). If the disease is accompanied by pain, find out the following details:

place of localization;

irradiation (where does it give?);

character (what does it resemble?);

intensity (how strong is it?);

time of onset (when does it start, how long does it last, and how often does it occur?);

the circumstances under which it occurs (environmental factors, emotional reactions or other circumstances);

factors that exacerbate or alleviate pain (physical or emotional stress, hypothermia, taking medications (what exactly, in what quantities), etc.);

concomitant manifestations (shortness of breath, arterial hypertension, ischuria, dizziness, tachycardia, dilated pupils, forced posture, facial expressions, etc.).

Similarly, other manifestations of the disease or condition of the patient (nausea and vomiting, stool retention, diarrhea, anxiety, etc.) can be detailed.

In the same section, they record what the patient himself thinks about his disease, what made him see a doctor, how the disease affected his life and activity.

In the life history section, all previous diseases, injuries, medical procedures, dates of previous hospitalizations, the patient's response to past treatment, and the quality of nursing care provided are indicated.

The patient's condition at the time of the examination, living conditions, habits, attitudes towards health make it possible to identify those strengths and weaknesses that must be taken into account when planning nursing care.

A family history makes it possible to assess the risk of a patient developing certain diseases that are hereditary in nature. If a family pathology is detected, relatives may be involved in the examination and treatment.

The psychological history helps to recognize the patient as a person, to assess his likely reactions to the disease, his mechanisms of adaptation to the situation, the strength of the patient, his anxiety.

Objective examination

The main task of an objective examination of the patient's organs and systems is to identify those important health problems that have not yet been mentioned in a conversation with the patient. Often, the patient's painful condition is caused by a disruption in the normal functioning of an organ or system as a whole. It is better to start clarifying the state of a particular system with general questions: "How is your hearing?", "Do you see well?", "How does your intestines work?". This will allow the patient to concentrate on the subject of the conversation.

The nursing process is not an obligatory component of nursing activity, therefore it is recommended to conduct a patient examination according to a certain plan in compliance with the necessary rules recommended during a medical examination.

An objective assessment of the patient's condition begins with a general examination, then proceeds to palpation (feeling), percussion (tapping), auscultation (listening). To be fluent in percussion, palpation and auscultation is the professional task of a doctor and a nurse with a higher education. The inspection data is entered into the SIB.

Assessment of the general condition of the patient

The patient's appearance and behavior should be assessed using observational data from the history and examination. Does the patient hear the nurse's voice well? Does he move easily? What is his walk like? What is he doing at the time of the meeting, sitting or lying down? What is on his bedside table: a magazine, postcards, a prayer book, a vomit container, or nothing at all? Assumptions made on the basis of such simple observations can help guide the choice of nursing care tactics.

Pay attention to how the patient is dressed. Is he neat? Is there an odor coming from it? You should pay attention to the patient's speech, follow the expression of his face, behavior, emotions, reactions to the environment, find out the state of consciousness.

The patient's state of mind. When evaluating it, you need to find out how adequately he perceives the environment, how he reacts to medical personnel, whether he understands the questions that are asked to him, how quickly he answers, whether he is inclined to lose the thread of the conversation, become silent or fall asleep.

If the patient does not answer questions, you can resort to the following methods:

speak loudly to him;

shake it slightly, as they do when they wake up a sleeping person.

If the patient still does not respond, it should be established whether he is in a state of stupor or coma. Impairment of consciousness can be short-term or long-term.

The Glasgow Coma Scale (GCS) is widely used to assess the degree of impaired consciousness and coma in children older than 4 years1 and adults. It consists of three tests for evaluation: eye opening response (E), speech (V) and motor (M) responses. After each test, a certain number of points are awarded, and then the total amount is calculated.

Table. Coma scale

Glasgow.

Interpretation of the results obtained:

15 points - clear consciousness;

13-14 points - stunning;

9-12 points - sopor;

6-8 points - moderate coma;

4-5 points - terminal coma;

3 points - death of the bark.

Positionpatient. It depends on the general condition. There are three types of patient position: active, passive and forced.

The patient, who is in an active position, easily changes it: sits down, gets up, moves around; serves himself. In the passive position, the patient is inactive, cannot independently turn, raise his head, arm, change the position of the body. This position is observed in the unconscious state of the patient or the state of hemiplegia, as well as in cases of extreme weakness. The patient takes a forced position to alleviate his condition. For example, with pain in the abdomen, he tightens his knees, with shortness of breath, he sits with his legs down, holding his hands to a chair, couch, bed. Suffering on the face, increased sweating testify to pain.

Growthandweightbodypatient. Find out what his usual body weight is, whether it has changed recently. The patient is weighed, normal body weight is calculated, his height is measured, and whether he has weakness, fatigue, or fever.

In patients with impaired nutritional requirements and excretion of waste products from the body, body weight and height data are used as the main indicators in the treatment. The height and weight of a person's body to a large extent depend on his regimen and nature of nutrition, heredity, previous diseases, socio-economic status, place of residence and even time of birth.

Nursing staff often have to determine the height and body weight of patients, especially in pediatric practice or at preventive examinations. The scale-height meter, produced by the medical industry, allows these measurements to be carried out with great time savings.

There is no consensus on the issue of normal body weight (proper weight) of an adult. With the simplest method of calculation, the normal body weight of a person should be equal to his height in centimeters minus 100. So, if a person is 170 cm tall, the normal body weight is 70 kg. When calculating ideal body weight, height, gender, age and body type are taken into account. To determine the ideal body weight, you must use special tables.

To measure body weight and height of a person, it is necessary to act according to a certain algorithm.

Table. The main body types of a person

Table. Ideal body weight of a person, taking into account his physique and height, kg *

Table. Ideal body weight for different age groups, taking into account the height of a person, kg Note. In table. used data from men and women who are not at risk. For people with an increased risk of developing cardiovascular disease and diabetes, the values ​​of normal body weight should be lower than those given.

Patient Height Measurement Algorithm

Purpose: assessment of physical development.

Indications: examination upon admission to the hospital or preventive examination.

Equipment: stadiometer, pen, case history.

Problems: the patient cannot stand. Stage 1. Preparation for the procedure 1. Gather information about the patient. Kindly introduce yourself to the patient. Find out how to contact him. Explain the course of the forthcoming procedure, obtain consent. Assess the patient's ability to participate in the procedure.

Rationale:

ensuring the psychological preparation of the patient for the upcoming procedure;

respect for the rights of the patient.

2. Lay an oilcloth or a disposable pad under your feet. Invite the patient to take off their shoes, relax, let down their hair for women with a high hairstyle.

Rationale:

ensuring the prevention of nosocomial infections;

obtaining reliable indicators. 2nd stage. Execution of a procedure.

3. Invite the patient to stand on the platform of the stadiometer with his back to the rack with the scale so that he touches it with three points (heels, buttocks and interscapular space).

Rationale:

4. Stand to the right or left of the patient. Rationale:

ensuring a safe hospital environment.

5. Slightly tilt the patient's head so that the upper edge of the external auditory canal and the lower edge of the orbit are on the same line, parallel to the floor.

Rationale:

providing reliable indicators.

6. Lower the tablet on the patient's head. Fix the tablet, ask the patient to lower his head, then help him get off the stadiometer. Determine the indicators by counting along the bottom edge.

Rationale:

providing conditions for obtaining a result;

7. Communicate the findings to the patient. Rationale:

ensuring the rights of the patient. 3rd stage. End of procedure

8. Remove the foot napkin from the height meter platform and throw it into the trash bin.

Rationale:

prevention of nosocomial infections.

9. Record the findings in the medical history. Rationale:

ensuring the continuity of nursing care. Note. If the patient is unable to stand, the measurement is taken while the patient is in a sitting position. The patient should be offered a chair. The fixation points will be the sacrum and the interscapular space. Measure your height while sitting. Record the results.

Algorithm for weighing and determining the patient's body weight

Purpose: to evaluate physical development or the effectiveness of treatment and nursing care.

Indications: preventive examination, diseases of the cardiovascular, respiratory, digestive, urinary or endocrine systems.

Equipment: medical scales, pen, case history.

Problems: the serious condition of the patient.

1st stage. Preparation for the procedure.

1. Collect information about the patient. Introduce yourself politely to him. Ask how to contact him. Explain the course of the procedure and the rules for its implementation (on an empty stomach, in the same clothes, without shoes; after emptying the bladder and, if possible, the intestines). Obtain patient consent. Assess the possibility of his participation in the procedure.

Rationale:

establishing contact with the patient;

respect for the rights of the patient.

2. Prepare the balance: align; adjust; close the shutter. Lay oilcloth or paper on the platform of the scales.

Rationale:

ensuring reliable results;

ensuring infectious safety. 2nd stage. Execution of a procedure.

3. Ask the patient to take off their outer clothing, take off their shoes and carefully stand on the center of the scale platform. Open shutter. Move the weights on the scales to the left until the level of the rocker arm coincides with the control.

Rationale:

providing reliable indicators.

4. Close shutter. Rationale:

ensuring the safety of scales.

5. Help the patient get off the weight platform. Rationale:

providing a protective regime.

6. Write down the data obtained (it must be remembered that a large weight serves to fix tens of kilograms, and a small one - for kilograms and grams).

Rationale:

determination of the compliance of the patient's actual body weight with the ideal one using the body mass index (BMI) - Quetelet index.

Note. BMI is equal to actual body weight divided by a person's height squared. With BMI values ​​in the range of 18-19.9, the actual body weight is less than normal; with BMI values ​​in the range of 20-24.9, the actual body weight is equal to the ideal; A BMI of 25-29.9 is indicative of a pre-obese stage, and a BMI of >30 indicates that the patient is obese.

7. Communicate data to the patient. Rationale:

ensuring the rights of the patient. 3rd stage. End of procedure.

8. Remove the napkin from the platform and throw it in the trash. Wash the hands.

Rationale:

prevention of nosocomial infections.

9. Enter the obtained indicators in the NIS. Rationale:

ensuring the continuity of nursing care.

Note. In the hemodialysis unit, patients are weighed in bed using special scales.

Assessment of the condition of the skin and visible mucous membranes

During examination, palpation (if necessary) of the skin and visible mucous membranes, attention should be paid to the following characteristics.

Coloration of the skin and mucous membranes. Examination reveals pigmentation or its absence, hyperemia or pallor, cyanosis or icterus of the skin and mucous membranes. Before the examination, you should ask the patient if he has noticed any changes in the skin.

There are several characteristic changes in the color of the skin and mucous membranes.

1. Hyperemia (redness). It can be temporary, caused by taking a hot bath, alcohol, fever, strong excitement, and permanent, associated with arterial hypertension, work in the wind or in a hot room.

2. Paleness. Paleness of a temporary nature can be caused by excitement or hypothermia. Severe pallor of the skin is characteristic of blood loss, fainting, collapse. Hyperemia and pallor are best seen on the nails, lips and mucous membranes, especially on the oral mucosa and conjunctiva.

3. Cyanosis (cyanosis). It can be general and local, central and peripheral. General characteristic of cardiovascular insufficiency. Local, for example, for thrombophlebitis. Central cyanosis is more pronounced on the lips and mucous membrane of the oral cavity and tongue. However, the lips take on a bluish tint even at low ambient temperatures. Peripheral cyanosis of nails, hands, feet can also be caused by excitement or low air temperature in the room.

4. Ictericity (jaundice) of the sclera indicates a possible pathology of the liver or increased hemolysis. Jaundice may appear on the lips, hard palate, under the tongue, and on the skin. Jaundice of the palms, face and soles may be due to the high content of carotene in the patient's diet.

Moisture and oiliness of the skin. The skin may be dry, moist or oily. Humidity of the skin, the condition of the subcutaneous tissue is assessed by palpation. Dry skin is characteristic of hypothyroidism.

The temperature of the skin. By touching the patient's skin with the back surface of the fingers, one can judge its temperature. In addition to assessing the overall temperature, it is necessary to check the temperature on any reddened area of ​​\u200b\u200bthe skin. In the inflammatory process, a local increase in temperature is noted.

Elasticity and turgor (elasticity). It is necessary to determine whether the skin easily gathers into a fold (elasticity) and whether it straightens quickly after that (turgor). A commonly used method for assessing skin elasticity is palpation.

Decreased elasticity and firmness of the skin, its tension is observed with edema, scleroderma. Dry and inelastic skin may indicate tumor processes and dehydration of the body. It should be borne in mind that with age, the elasticity of human skin decreases, wrinkles appear.

Pathological elements of the skin. When pathological elements are detected, it is necessary to indicate their features, localization and distribution on the body, the nature of the location, the specific type and time of their occurrence (for example, with a rash). Itching of the skin can result in scratching, which leads to the risk of infection of the patient. During examination, it is necessary to pay special attention to them, since the cause of their occurrence can be not only dry skin, allergic reactions, diabetes mellitus or other pathology, but also scabies.

Hair cover. On examination, it is necessary to pay attention to the nature of hair growth, the amount of hair of the patient. People often worry about hair loss or excessive hair growth. Their feelings need to be taken into account when planning nursing care. A thorough examination allows you to identify individuals with pediculosis (lice).

Detection of pediculosis and scabies is not a reason for refusing hospitalization. With timely isolation and appropriate sanitization of patients, their stay in the walls of the medical facility is safe for others.

Nails. It is necessary to inspect and feel the nails on the hands and feet. Thickening and discoloration of the nail plates, their fragility can be caused by a fungal infection.

The condition of the hair and nails, the degree of their grooming, the use of cosmetics will help to understand the personal characteristics of the patient, his mood, lifestyle. For example, regrown nails with half-worn varnish, long-unpainted hair may indicate a patient's loss of interest in their appearance. An untidy appearance is characteristic of a patient with depression or dementia, but the appearance should be judged based on the likely norm for a particular patient.

Assessment of the state of the sense organs

organs of vision. An assessment of the condition of the patient's organs of vision can be started with the questions: "How is your vision?", "Do your eyes bother you?". If the patient notes a deterioration in vision, it is necessary to find out whether this happened gradually or suddenly, whether he wears glasses, where and how he stores them.

If the patient is concerned about pain in or around the eyes, watery eyes, redness, he should be reassured. Explain that the decrease in vision may be due to the patient's adaptation to the conditions of the hospital, taking medications.

The nursing care plan should be tailored to the patient's vision problems.

Hearing organs. Before proceeding with their examination, you should ask the patient if he hears well. If he complains of hearing loss, it is necessary to find out whether it affects both ears or one, whether it happened suddenly or gradually, whether it was accompanied by discharge or pain. You need to find out if the patient wears a hearing aid, and if so, the type of hearing aid.

Using the information received about hearing loss and visual acuity, the nurse will be able to communicate effectively with the patient.

Organs of smell. First you need to find out how prone the patient is to colds, whether he often notes nasal congestion, discharge, itching, and whether he suffers from nosebleeds. If the patient has allergic rhinitis, the nature of the allergen and previously used methods of treating this disease should be clarified. Pollinosis, pathology of the paranasal sinuses should be identified.

Oral cavity and pharynx. When examining the oral cavity, you need to pay attention to the condition of the patient's teeth and gums, ulcerations on the tongue, dry mouth, if there are dentures, check their fit, find out the date of the last visit to the dentist.

Poorly fitting dentures can be an obstacle to communication with the patient and cause speech disorders, plaque on the tongue - the cause of bad smell and reduced taste sensations, and sore throat and soreness of the tongue - the cause of difficulty in eating. All this must be taken into account when planning nursing care.

Upper Body Assessment

Head. First of all, you need to find out if the patient has complaints of headache, dizziness, or if there have been injuries. Headache is a very common occurrence in patients of all ages. It is necessary to find out its character (constant or pulsating, acute or dull), localization, for the first time it arose or is characterized by a chronic course. With migraine, not only headache is often observed, but also its accompanying symptoms (nausea and vomiting).

Neck. On examination, various swellings, swollen glands, goiter, and pain are revealed.

Assessment of the state of the mammary glands

During the examination, it is found out whether the woman makes an independent examination of the mammary glands, whether there is a feeling of discomfort in the mammary gland, whether the woman is observed by an oncologist, whether there are menstrual irregularities, whether there is engorgement and soreness of the glands in the premenstrual period.

With discharge from the nipple, they specify when they appeared, their color, consistency and quantity; they are secreted from one or both glands. The examination may reveal asymmetry of the mammary glands, engorgement, induration, absence of one or both mammary glands.

If the patient does not know how to independently perform breast examinations, training in these techniques can be included in the nursing care plan.

Pathology of the mammary glands is quite common in women, including young women. It must be remembered that the loss of the mammary gland can be a great psychological trauma for a woman and affect the satisfaction of her needs for sex. Nursing staff should treat young patients who have undergone a mastectomy with special tact and attention.

Assessment of the state of the musculoskeletal system

To determine the state of this system, you must first find out if the patient is worried about pain in the joints, bones and muscles. When complaining of pain, one should find out their exact localization, area of ​​​​distribution, symmetry, irradiation, nature and intensity. It is important to determine what contributes to the increase or decrease in pain, how physical activity affects it, and whether it is accompanied by any other symptoms.

On examination, deformations, limited mobility of the skeleton, joints are revealed. When limiting joint mobility, it is necessary to find out which movements are impaired and to what extent: can the patient freely walk, stand, sit, bend over, get up, comb his hair, brush his teeth, eat, dress, wash. Restriction of mobility leads to restriction of self-service. Such patients are at risk of developing bedsores, infections and therefore require increased attention from nursing staff.

Assessment of the state of the respiratory system First of all, it is necessary to pay attention to the change in the patient's voice; frequency, depth, rhythm and type of breathing; chest excursion, assess the nature of shortness of breath, if any, the patient's ability to tolerate physical activity, find out the date of the last x-ray examination.

Both acute and chronic pathology of the respiratory system can be accompanied by a cough. It is necessary to determine its nature, quantity and type of sputum, its smell. Particular attention should be paid to hemoptysis, chest pain, shortness of breath, since their cause, like cough, can be a serious pathology of the cardiovascular system.

Assessment of the state of the cardiovascular system

Pulse and blood pressure are usually determined before assessing the state of the cardiovascular system. When measuring the pulse, it is necessary to pay attention to its symmetry on both hands, rhythm, frequency, filling, tension, deficiency.

When the patient complains of pain in the region of the heart, it is necessary to clarify its nature, localization, irradiation, duration. In the case of a prolonged or repeated illness, it is necessary to determine which drugs the patient usually relieves pain.

Patients are often worried about the heartbeat. They say that the heart "freezes", "pounds", "jumps", they note painful sensations. It is necessary to find out what factors cause a heartbeat. It does not necessarily mean serious heart problems.

A characteristic sign of cardiovascular pathology is edema. They occur due to the accumulation of fluid in the tissues and cavities of the body. There are hidden (not visible during external examination) and obvious edema.

Obvious edema is easy to identify by changes in the relief of certain parts of the body. With leg edema in the area of ​​the ankle joint and foot, where there are bends and bony protrusions, they are smoothed out. If, when pressing on the skin and subcutaneous fat with a finger, where they are closest to the bone (the middle third of the anterior surface of the lower leg), a long-lasting fossa forms in this place, which means that there is edema. The skin becomes dry, smooth, pale, less sensitive to heat, and its protective properties are reduced.

The appearance of obvious edema is preceded by a latent period, during which the body weight of a person increases, the amount of urine excreted by him decreases, several liters of fluid are retained in the body, hidden edema appears. It is important to be able to recognize them. This can be done by daily weighing in the morning and determining the patient's water balance. Water balance is the ratio of the amount of fluid taken by the patient per day to the amount of urine he has excreted.

Then they find out the time and frequency of occurrence of edema, their localization, connection with excessive consumption of fluid or salt, with somatic diseases.

Edema is local and general, mobile and immobile. In diseases of the heart and peripheral vessels, if the patient is not bedridden, orthostatic edema may appear in the lower parts of the body - on the feet and legs. Puffiness of the eyelids and hands, if it is combined with swelling of other parts of the body, is observed in diseases of the kidneys. An increase in waist size may be a sign of ascites (abdominal dropsy). Cachectic edema develops with extreme exhaustion of the body, for example, in patients at the last stage of oncological diseases.

Edema can affect internal organs and cavities. The accumulation of transudate in the abdominal cavity is called ascites, in the pleural cavity - hydrothorax (chest dropsy); extensive swelling of the subcutaneous tissue is called anasarca.

Dizziness, fainting, numbness and tingling in the extremities are signs of hypoxia, a characteristic phenomenon in the pathology of the cardiovascular system and respiratory failure. They lead to an increased risk of falls and injury to the patient.

A detailed assessment of the state of the patient's cardiovascular and respiratory systems makes it possible to judge the degree of satisfaction of the need for oxygen, which occupies a leading place in the life of the body.

Assessment of the state of the gastrointestinal tract (GIT)

Based on the information obtained about the state of the patient's gastrointestinal tract, one can judge the degree of satisfaction of his needs for food, drink, excretion of waste products from the body.

It is necessary to find out from the patient whether he has appetite disturbances, heartburn, nausea, vomiting (special attention should be paid to hematemesis), belching, indigestion, problems with swallowing.

Inspection is advisable to start with the tongue - the mirror of the stomach. You should pay attention to plaque and breath, assess the patient's appetite, find out his eating habits, nutritional pattern. It is necessary to note the shape and size of the abdomen, its symmetry. In case of emergency, nursing personnel perform superficial palpation of the abdomen. In case of acute pain of unknown origin, it is urgent to invite a doctor.

Significant indicators characterizing the state of the gastrointestinal tract are the frequency of stool, its color, and the amount of feces. Normally, a person passes stool at the same time every day. We can talk about its delay if it is absent for 48 hours. Fecal incontinence is often associated with diseases of the central nervous system. Defecation disorders can be caused not only by organic pathology, but also by the psychological state of the patient.

After a nursing interview and examination, the nurse records in the SIS the information received about bleeding from the rectum or tarry stools, hemorrhoids, constipation, diarrhea, abdominal pain, intolerance to certain foods, flatulence, jaundice associated with the pathology of the liver and gallbladder, etc. Information about a colostomy or ileostomy will help to create an individual plan for nursing care, teaching relatives how to properly care for the patient.

Assessment of the state of the urinary system

During a nursing survey and examination, it is necessary to assess the nature and frequency of urination in a patient, the color of urine, its transparency, to identify disorders of the urinary system (qualitative and quantitative). Urinary and fecal incontinence is not only a risk factor for the development of bedsores in a patient, but also a big psychological and social problem.

If the patient has an indwelling catheter or has had a cystostomy, nursing staff should plan activities to adapt the patient to the environment, as well as to prevent infection of the organs of his urinary system.

Assessment of the state of the endocrine system

When assessing the endocrine system, nursing staff should pay attention to the nature of the patient's body hair, the distribution of subcutaneous fat, and the visible enlargement of the thyroid gland. Often, endocrine system disorders associated with changes in appearance become the cause of the patient's psychological discomfort.

Assessment of the state of the nervous system

Find out if the patient had episodes of loss of consciousness, convulsions, whether he sleeps well. It is necessary to ask the patient about his dreams, the duration and nature of sleep (deep, calm or superficial, restless). It is important to find out whether the patient uses sleeping pills, if so, which ones, and how long ago he began to use them.

The manifestation of neurological disorders in the patient may be headache, loss and change in sensitivity.

With a tremor of the limbs, a violation of the gait of the patient, you should find out if he had a head or spine injury in the past. The actions of nursing staff should be aimed at ensuring the safety of such a patient during his stay in the hospital.

If the patient's motor activity is limited due to weakness, paresis or paralysis, special measures for the prevention of pressure ulcers should be included in the nursing care plan.

Assessment of the state of the reproductive system

In women, find out the time of the onset of the first menstruation (menarche); regularity, duration, frequency, amount of discharge; date of last menstruation. It is necessary to find out whether the patient has bleeding in the intermenstrual period, whether she suffers from dysmenorrhea, premenstrual syndrome, whether her well-being changes during menstruation.

Many girls are concerned about irregular or delayed periods. By asking questions, the nurse can understand the extent to which the patient is aware of the female genital area.

In a middle-aged woman, it should be found out whether her menstruation stopped and when, whether its cessation was accompanied by any symptoms. You can also ask how she took this event, whether menopause affected her life in any way.

During a nursing survey and examination, discharge, itching, ulceration, and swelling of the genital organs are revealed. In the NIB, the transferred venereal diseases, methods of their treatment are noted; the number of pregnancies, childbirth, abortions; methods of contraception; the patient's sexual preference.

In men, the state of the reproductive system is found out after checking the condition of the urinary tract. The questions asked are aimed at identifying local symptoms that indicate violations of sexual function.

It is very important to find out from the patient what conditions and circumstances (the patient's general condition, drugs taken, alcohol consumption, sexual experience, relationships between sexual partners) caused or contributed to sexual dysfunction. When talking to patients on this topic, nursing staff should use the techniques of therapeutic communication and the greatest sense of tact.

After completing the survey and examination, the patient should be given the initiative by asking him a leading question: "What have we not talked about yet?" or asking: "Do you have any questions for me?". It is necessary to explain to the patient what awaits him next, to acquaint him with the daily routine, employees, premises, neighbors in the ward, and give a memo about his rights and obligations.

At the end of the examination, the nursing staff draws conclusions about the violation of the patient's needs, fixes them in the SIS.

In the future, the dynamics of the patient's condition should be displayed daily in the observation diary (NIB, p.) throughout the entire stay in the hospital.

The first steps in the practice of nursing staff are cautious and uncertain. When examining patients, students sometimes worry more than the patient himself. Often there is a feeling of awkwardness and insecurity. The interrogation turns into an interrogation, the examination drags on. Touching the intimate parts of the patient's body causes a feeling of shame. In these cases, you should try to master yourself, stay calm, collected, as confident as possible. The skills of conducting an educational case history help in the future to competently and fully conduct a nursing survey.

If the conversation with the patient is already over, and you realize that you missed something important, you can go back and politely say that something needs to be clarified. You can not give out your irritation, anxiety, disgust. A medical worker has no right to negative emotions at the patient's bedside.

Self-confidence comes with time. With the acquisition of practical skills, the process of nursing examination becomes a familiar procedure, carried out without causing any particular inconvenience to the patient. Experienced nursing staff pays attention to the patient's reactions, and not to their own experiences. Improving professionalism for a true physician becomes a matter of his whole life.

conclusions

1. The collection of information about the patient at the first stage of the nursing process has a huge impact on the quality of subsequent nursing care. The main sources of information about the patient are himself, his relatives and friends, medical personnel, medical documentation, special medical literature.

2. There are two types of patient information: subjective and objective. The collection of subjective information is carried out with the help of a survey. First, personal data is recorded indicating the source of information.

3. Subjective examination includes the collection of main complaints, medical history, life history, self-assessment of the patient's condition at the time of examination, family and psychological history.

4. During an objective examination, the nursing staff determines the general condition of the patient, measures his height, body weight, temperature; assesses the state of vision, hearing, skin and visible mucous membranes, musculoskeletal, respiratory, cardiovascular, urinary, reproductive, endocrine, nervous systems, gastrointestinal tract.

5. Distinguish between clear and confused (inhibited, deafened, stupor) states of consciousness.

6. An objective examination reveals the position of the patient: active, passive and forced.

7. To assess the compliance of the body weight of a patient of a certain height and age with the ideal body weight, special tables should be used.

8. When examining the skin and visible mucous membranes, its color, moisture and fat content, temperature, elasticity and turgor are evaluated, pathological elements on the skin and its appendages are detected.

9. When examining the musculoskeletal system, first of all, they find out if the patient has pain in the joints and muscles, if so, then their nature, bone deformities, limitation of mobility.

When examining the respiratory system, they find out the characteristics of breathing; during the examination, the pulse, blood pressure, pain in the heart area, and edema are recorded.

When examining the gastrointestinal tract, appetite disturbances, heartburn, nausea, vomiting, belching, flatulence, constipation or diarrhea are noted.

When examining the urinary system, the nature and frequency of urination, the color of urine, its transparency, and the fact of urinary incontinence are determined.

When examining the endocrine system, they find out the nature of hair growth, the distribution of fat on the body, and an increase in the thyroid gland.

As part of the examination of the nervous system, attention is paid to the nature of sleep, tremors, gait disturbances, episodes of loss of consciousness, convulsions, sensory disturbances, etc.

When examining the reproductive system in women, a gynecological history is collected; in men, following the clarification of the state of the urinary tract, pathologies of the reproductive system are detected.

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Founder of modern nursing. Our compatriots in the history of nursing. The concept of nursing process. The nursing process consists of five main steps. Nursing examination. Formulation of a nursing diagnosis.

Nursing Process is one of the basic and integral concepts of modern models of nursing. The concept of the nursing process was born in the United States in the mid-1950s. Currently, it has been widely developed in the American, and since the 80s - in the Western European models of nursing.

disadvantage in the development of nursing in Russia today is the lack of common terminology and definitions of certain concepts for all medical workers. Often the meanings of concepts such as problem, by

need, symptom match up. This leads to confusion. Doctors today have an International Classification of Diseases, which allows them to understand each other. At nurses in Russia, attempts to unify and standardize the professional language have not yet had any results.

Within the WHO European Region, nurses who plan to apply the nursing process are encouraged to use the model proposed by Virginia Henderson, based on the physiological, psychological and social needs assessed by nurses.

Currently nursing process(the word "process" means the course of events, its stages) is the core of nursing education and creates a theoretical scientific basis for nursing care in Russia.

Nursing Process is a scientific method of organizing and delivering nursing care, a systematic way of identifying the situation in which the patient and the nurse are, and the problems that arise in this situation, in order to implement a plan of care acceptable to both parties. The nursing process is a dynamic, cyclical process.

The goal of the nursing process is to maintain and restore the patient's independence in meeting the basic needs of the body, requiring an integrated (holistic) approach to the patient's personality.

The goal of the nursing process is achieved through:

creating a database of information about the patient;

determining the patient's nursing needs

designation of priorities in nursing care, their priority;

setting goals and drawing up a care plan, mobilizing the necessary resources;

implementation of the plan, that is, the provision of nursing care directly and indirectly;

■ evaluating the effectiveness of the patient care process and achieving the goal of care.

The nursing process brings a new understanding of the role of a nurse in practical health care, requiring her not only to have technical training, but also the ability to be creative in caring for patients, the ability to individualize and systematize care in order to prevent, reduce, and eliminate patient care problems.

Specifically, nursing process involvesscientific methods for determining health carespecific needs of the patient, family or society, as well asthe selection of those that can be most effectiveeffectively satisfied through nursing earYes, with the indispensable participation of the patient or his membersfamilies.

The nursing process consists of five main steps. It is known that until the mid-1970s in the United States, the nursing process had four stages (examination, planning, implementation, evaluation). The diagnostic phase was removed from the examination phase in 1973 due to the approval of the standards of nursing practice by the American Nurses Association.

Istage- nursing examination or a situation assessment to assess the specific needs of the patient and the resources needed for nursing care. This phase of the nursing process includes evaluation processtuations methods of nursing examination. During the examination, the nurse collects the necessary information by interviewing (structured interviewing) the patient, relatives, medical workers.

Before interviewing a patient, review the patient's medical records, if possible. Recall the factors and techniques that increase the effectiveness of communication:

the ability to conduct a conversation;

check the correctness of the patient's perception of your questions;

w ask open-ended questions;

observe pauses and culture of speech;

show the ability to present yourself;

take an individual approach to the patient. Techniques such as communicating with the patient in a way that

intelligence, slow pace of conversation, respect for confidentiality, listening skills will increase the effectiveness of the interview and help the nurse improve her skills and abilities.

Don't make mistakes in your survey. Don't ask questions that require a yes or no answer. State your questions clearly. Remember that during the interview, the patient can provide information about himself in any order. Do not demand answers from him according to the scheme given in the nursing story. Memorize his answers and record exactly as planned in the patient's health (illness) history. Use information from the medical history (prescription sheet, temperature sheet and etc.) and other sources of information about the patient.

Patient Examination Methods

There are the following examination methods: subjective, objective and additional examination methods to determine the patient's needs for care.

1. Collection of necessary information:

a) general information about the patient (last name, first name, patronymic, age), subjective data: current complaints, both physiological, psychological, and social, spiritual; the patient's feelings; reactions associated with adaptive (adaptive) capabilities; information about unmet needs associated with a change in health status or a change in the course of the disease;

b) objective data. These include: height, body weight, facial expression, state of consciousness, position of the patient in bed, condition of the skin,

patient's body temperature, respiration, pulse, blood pressure, natural functions and other data; c) assessment of the psychosocial situation in which the patient is:

social and economic data are assessed, risk factors are determined, environmental data that affect the patient's health status, his lifestyle (culture, hobbies, hobbies, religion, bad habits, national characteristics), marital status, working conditions, financial situation etc.;

the nurse evaluates the observed behavior, the dynamics of the emotional sphere.

The collection of the necessary information begins from the moment the patient enters the health facility and continues until he is discharged from the hospital.

2. Analysis of the collected information. The purpose of the analysis is to determine the priority (according to the degree of threat to life) violated needs or problems of the patient, the degree of independence of the patient in care (independent, partially dependent, dependent on the environment, medical workers).

Subject to the skills and abilities of interpersonal communication, ethical and deontological principles, the skills of questioning, observation, assessment of the condition, the ability to document the patient's examination data, the examination is usually successful.

II stage- nursing diagnosis, or detectionpatient problems. This stage can also be called nursing diagnosis. The analysis of the information received is the basis for formulating the patient's problems, existing (real, obvious) or potential (hidden, which may appear in the future). When prioritizing, the nurse should rely on the medical diagnosis, know the patient's lifestyle, risk factors that worsen his condition, be aware of his emotional and

148

psychological state and other aspects that help her make a responsible decision - identifying the patient's problems, or making nursing diagnoses. The process of making a nursing diagnosis is very important, it requires professional knowledge, the ability to find a connection between the signs of deviations in the patient's condition and the causes that cause them.

Sister diagnosis is a patient's health condition (current and potential), established as a result of a nursing examination and requiring intervention from a nurse.

The North American Association of Nursing Diagnosis NANDA (1987) issued a list of diagnoses that is driven by the patient's problem, its cause, and the nurse's direction of action. Onexample:

Anxiety associated with the patient's anxiety about the water of the upcoming operation.

Risk of pressure sores due to prolonged immobilization.

3. Violation of the bowel function: constipation due to insufficient intake of roughage.

The International Council of Nurses (ICM) developed (1999) the International Classification of Nursing Practices (ICSP) is a professional information tool necessary for standardizing the professional language of nurses, creating a single information field, documenting nursing practice, recording and evaluating its results, training and etc.

In the context of the ICFTU under nursing diagnosis understand the nurse's professional judgment about the health or social event that is the object of nursing interventions.

The disadvantages of these documents are the complexity of the language, the peculiarities of culture, the ambiguity of concepts, and more.

Today in Russia there are no approved nursing diagnoses.

149

Stage III - setting goals for the nursing interventionstva, those. defining, together with the patient, the desired outcomes of care.

In some models of nursing, this stage is called planning.

Planning should be understood as the process of setting goals (that is, the desired outcomes of care) and planning the nursing interventions needed to achieve these goals. The planning of the nurse's work to meet the needs must be carried out in order of priority (first priority) of the patient's problems.

Stage IV - planning the scope of nursing interventionsevidence and implementation(performance) nursing parade ground

■ interventions(care).

In models where planning is the third stage, the fourth stage is the implementation of the plan. Planning includes:

Definition of types of nursing interventions.

Discussing the care plan with the patient.

Introducing others to the care plan. Implementation- it:

Completion of the care plan on time.

Coordination of nursing services in accordance with the agreed plan.

Coordination of care, taking into account any care provided but not planned, or care planned but not provided.

Stage V - evaluation of results (final evaluation of nursing care). Evaluation of the effectiveness of the care provided and its correction, if necessary.

Stage V - includes:

Comparison of the achieved result with the planned one.

Evaluation of the effectiveness of the planned intervention.

Further evaluation and planning if desired results are not achieved.

Critical analysis of all stages of the nursing process and making the necessary amendments.

The information obtained during the assessment of the results of care should form the basis for the necessary changes, subsequent interventions (actions) of the nurse.

Documentation of all stages of the nursing process is carried out in the nursing record of the patient's health and is known as the nursing history of the patient's health or illness, of which the nursing record is an integral part. Currently only nursing documentation is being developed.

TOPIC: NURSING CARE PROCESS

learning goals

The student must

know:

basic concepts and terms;

purpose of the nursing process;

stages of the nursing process, their relationship and the content of each stage;

the importance of nursing examination in identifying patient problems and solving them;

the content of the information collected by the nurse about the patient;

sources of information;

methods of examination of patients;

types of shortness of breath"

types of physiological and pathological respiration;

importance of nursing and medical records.

be able to:

explain the need to introduce the nursing process into nursing education and practice;

conduct a survey by a subjective method, a survey of the patient and his non-medical environment;

interpret the received data;

evaluate physical examination data:

appearance;

consciousness;

position in bed;

diaper rash and moisture of the skin and mucous membranes;

the presence of edema;

register survey data in nursing documentation;

communicate with the patient and his relatives;

examine with an objective method;

measure height, determine body weight;

count the respiratory rate, examine the pulse;

measure blood pressure, body temperature;

mark the indicators of the patient's functional state with a digital and graphic record: T °, ​​NPV, Ps, blood pressure, height, weight, daily diuresis.

Questions for self-study

Define the term "nursing process".

State the purpose of the nursing process.

List the steps in the nursing process.

Briefly describe the content of each step of the nursing process.

Consider the structure and meaning of nursing process documentation.

Describe the benefits of introducing the nursing process into practical health care.

The content of the nursing examination.

Sources of information about the patient.

Patient examination methods.

The content of the subjective method of examination.

The content of the objective method of examination.

Subjective and objective examination for every need.

Definition of anthropometry.

Normal NPV, Ps, AD.

Determination of water balance.

Documentation of received data.

Glossary

Terms

Wording

Algorithm

A set of rules chosen in a certain way and in a certain order to solve a given problem.

Medical diagnosis

Identification of a specific disease or pathological process.

Problem

A difficult situation that prevents predicting the course of events.

Priority

Nursing problem requiring immediate nursing intervention.

Need

A perceived psychological or physiological deficiency of something, reflected in the perception of a person.

primary need

Innate physiological needs, such as the need to survive.

secondary need

Needs that are psychosocial in nature, such as for success, power, respect, etc.

Setting Priorities

The process of deciding which tasks in a given situation should be performed immediately (now) and which at a later stage.

Procedure

The enterprise, regarding what actions should be taken in a particular situation.

Result

The goal to be achieved. In health care, this is a concept that refers to changes in the patient's state of health as a result of a particular event or the implementation of a pre-planned program.

Nursing medical history

Documented information about the patient's state of health, changes in his lifestyle, socio-cultural role, spiritual and emotional reactions to the disease; reflection of the conduct of the nursing process.

Stress

A situation characterized by increased physiological and psychological tension.

stressor

Stress factor.

Strategy

An overall comprehensive plan to achieve the goal.

Tactics

Short-term strategy to achieve the goal.

Nursing Process

A systematic approach to the provision of nursing care (care), focused on the needs of the patient.

Nursing examination

Collection of information about the patient's health status, his personality, lifestyle and reflection of the data obtained in the nursing history of the disease.

Nursing diagnosis

A clinical judgment by a nurse that describes the nature of a patient's present or potential response to a disease and condition, preferably indicating the cause of the response.

nursing planning

Definition of goals and objectives of nursing care (care) with forecasting the expected results of this care (care)

Medical examination

Conducting a physical examination using objective methods (palpation, percussion, auscultation, anthropometry, etc.) to collect a database of information about the patient.

subjective information

The patient's own feelings about their health problems.

objective information

Observations, measurements carried out by the person collecting information.

nursing intervention

Assessment of nursing care (care)

The process of analyzing patient responses to nursing intervention.

Patient-focused goal

A specific, achievable goal set to achieve the highest level of patient health and independent functioning.

cyanosis, acrocyanosis

Cyanosis, peripheral cyanosis.

jaundice

icterus

Confused mind

The patient answers questions correctly, but late.

Stupor

States of stunning, stupor, the patient answers questions late and meaninglessly.

Sopor

Pathological deep sleep, the patient is unconscious, reflexes are not preserved. A loud voice can bring him out of this state, but he soon falls back to sleep.

Coma

Complete depression of the central nervous system: consciousness is absent, muscles are relaxed, loss of sensitivity and reflexes

Sputum

Pathological secretion of the upper respiratory tract

Hemoptysis

The appearance of streaks of blood in the sputum, a harbinger of pulmonary hemorrhage.

Pulmonary bleeding

The appearance of a cough blood

hydrothorax

Accumulation of fluid in the pleural cavity

Pneumothorax

Air entering the pleural cavity

Apnea

Respiratory arrest

Dyspnea

Shortness of breath is a violation of the frequency, depth and rhythm of breathing.

expiratory dyspnea

Shortness of breath with difficulty exhaling (pulmonary)

Inspiratory dyspnea

Shortness of breath with difficulty breathing (cardiac)

Mixed dyspnea

Shortness of breath with difficulty inhaling and exhaling

Tachypnea

Rapid breathing

Bradypnea

Rare breath

Arrhythmia

Rhythm disturbance

Asphyxia

Suffocation followed by respiratory arrest.

Asthma

An asthma attack (severe shortness of breath) of pulmonary or cardiac origin.

arterial pulse

Vibration of the walls of the arteries caused by the work of the heart.

Tachycardia

Increased heart rate over 85 - 90 pulse waves per minute.

Bradycardia

Decreased heart rate less than 60 pulse waves per minute.

thready pulse

Pulse very small filling , voltage , very frequent (more than 120 p. v. per minute), it is difficult to palpate.

Melena or tarry stools

Black feces may be due to gastrointestinal bleeding

Colorless feces (white)

Jaundice symptom (infectious or mechanical)

Diarrhea

Frequent loose stools

Constipation (constipation)

Stool retention for more than 48 hours

Tenesmus

False urge to defecate or urinate

Nausea

Feeling of heaviness in the epigastric (epigastric)

Areas (harbinger of vomiting)

Vomit

Reflex act, contraction of the walls of the stomach and diaphragm, followed by ejection of the contents to the outside (may be central - not associated with diseases of the gastrointestinal tract and peripheral - associated with diseases of the gastrointestinal tract)

Vomiting "coffee grounds"

symptom of stomach bleeding

Belching

Weak contraction of the walls of the stomach, followed by the ejection of part of its contents into the oral cavity

Heartburn

Burning sensation along the esophagus

hiccup

Convulsive contraction of the diaphragm (may be of a nervous nature)

Diuresis

The amount of urine excreted in a certain period of time (can be day, night, daily, and even hourly)

Water balance

The balance between the liquid drunk and the food eaten and the liquid excreted from the body per day (normally 1.5 - 2 liters)

Dysuria

urinary disorder

Pollakiuria

Frequent urination

stranguria

Difficulty urinating

Polyuria

Daily diuresis more than 2 liters

Oliguria

Daily diuresis less than 500 ml.

Ishuria

Urinary retention due to accumulation of urine in the bladder due to the inability to urinate spontaneously

Anuria

Complete cessation of urine flow to the bladder

Uremia

The entry of nitrogenous slags into the blood (urinary blood) - self-poisoning of the body with its own decay products occurs as a result of renal failure

Hematuria (meat-colored urine)

Blood in the urine

albuminuria, proteinuria

Protein in the urine

Glucosuria

Sugar in urine

Edema

Accumulation of fluid in soft tissues

Anasarka

Edema of the whole body

hydrothorax

Accumulation of fluid in the chest

Ascites

Accumulation of fluid in the abdomen

Anthropometry

Measurement of height, body weight

Arterial pressure

Blood pressure on artery walls during systole and diastole

Systolic pressure

Blood pressure on artery walls during systole (maximum)

diastolic pressure

Blood pressure on artery walls during diastole (minimum)

Hypertension (hypertension)

Elevated blood pressure (above 139∕89)

Hypotension (hypotension)

Low blood pressure (below 110∕70)

Theoretical part

Nursing Process

1 . Nursing Process is a method of organizing and delivering nursing care, which

includes the patient and the nurse as interacting persons.

2. Nursing process - it is a systematic approach to the provision of nursing care (care), focused on the needs of the patient.

The nursing process of patient care isfrom three main parts:

Target .

Organization .

Creative skills (Table 1).

Table No. 1

Overall Purpose of the Nursing Process :

1. Prevent, alleviate, minimize patient problems on an individual basis.

2. Maintaining and restoring the patient's independence in meeting the basic needs of his body or peaceful death

The essence of the nursing process is:

specification of the patient's problems,

definition and further implementation of the nurse's action plan in connection with the identified problems and

evaluating the results of nursing intervention.

Today in Russia, the need to introduce the nursing process in healthcare institutions remains open. Therefore, the educational and methodological center for scientific research in nursing at the FVSO MMA named after. THEM. Sechenov together with the St. Petersburg regional branch of the all-Russian public organization "Association of Nurses of Russia" conducted a study to clarify the attitude of medical workers to the nursing process and the possibility of its implementation in practical healthcare. The study was conducted by the method of questioning.

Out of 451 interviewed physicians (nurses and doctors) to the question “Do you have an idea about the nursing process?” the main part of all respondents (64.5%) answered that they had a complete understanding, and only 1.6% of the survey participants answered that they had no idea about the nursing process.

1. Purpose of the nursing process you can name what it aims to achieve. The objectives of the nursing process include:

Determining the patient's care needs.

Determination of care priorities and expected goals and outcomes of care.

3. Formulate a plan of care for the patient, aimed at meeting the needs
patient.

4. Evaluation of the effectiveness of nursing care.

2. Organizational structure The nursing process consists of 5 steps:

1) examination - collection of information about the patient's health status;

2) nursing diagnosis - identification and designation of existing and potential
patient problems requiring nursing intervention;

3) care planning - definition of a program of action, definition of goals and objectives
nursing care.

performance - actions (interventions) necessary for the implementation of the plan.

5) grade - study of the patient's reactions to the nurse's intervention, determination of the degree
nor the achievement of goals and the quality of honey. help.

3. Creative skills - this is the nursing process itself, deepening and expanding existing knowledge.

The first step in the nursing process is the examination.

Defined as the ongoing process of collecting and reporting patient health data.

Target : collect information about the patient

Types of information collected by the nurse.

1. Physiological data (from medical history and physical examination).

2. Development Data (development of 1-2 years of life).

3. Psychological data (individual character traits, self-esteem, ability to

Make decisions).

4. Sociological data (functions, relationship, sources).

5. Cultural data (ethnic and cultural values).

6. Spiritual data (spiritual values, religiosity, etc.).

7 .Environmental data (pollution, natural disasters, etc.).

Table number 2

The information collected in the survey must be complete, accurate, descriptive, and must not contain controversial statements.

The data can beobjective and subjective .

Nursing process. Subjective examination

subjective the data includes the patient's assumptions about the state of health. Subjective data are feelings and emotions expressed in words, facial expressions, gestures. Only the patient himself can give this kind of information.Sources of information are:

Patient (best source).

Family, relatives, friends

Other medical professionals.

Patient's medical documents (medical record, etc.).

Review of medical literature.

Each source provides information about the patient's health status, risk factors, medical methods of examination and treatment, the characteristics of the disease, the need to provide medical care to the patient, etc.

Only the patient himself can give detailed and accurate information.

Families of patients may be interviewed about infants and children, the critically ill, the mentally retarded, and the unconscious.

To collect subjective information, the nurse interviews the patient - questioning.

During the interview, the nurse uses specific communication skills to help the patient become aware of the changes that are taking place or will take place in his lifestyle. During the interview, the nurse receives information about the physical, evolutionary, intellectual, social and spiritual characteristics of the patient.

Physical and evolutionary features reflect normal functioning and pathological changes in a person's lifestyle caused by illness, injury, or a developing crisis.

Questioning provides an opportunity to observe the patient. During the observation, the nurse determines whether the data obtained during the observation are consistent with those obtained through verbal communication.

For example, if a patient claims not to be worried about an upcoming examination but appears anxious and irritable, then the evidence is inconsistent.

When questioned, the patient also receives information that interests him: about the medical and sanitary environment, methods of treatment, the upcoming examination.

The patient needs this information to participate in care planning.

The interview is the first step in establishing contact between the nurse and the patient. in the future, the nurse will have to conduct training and counseling of the patient.

This relationship between nurse and patient should be based on understanding the patient's problems, caring for him and trusting each other.

general information about the patient;

questioning the patient;

current patient complaints;

the history of the patient's health or illness: social information and living conditions, information about habits, allergic anamnesis, gynecological (urological) and epidemiological anamnesis;

heredity;

pain, localization, nature, intensity, duration, frequency, response to pain.

COMMUNICATION STRATEGY

The working part (the question itself). When preparing for the interview, you must:

get acquainted with the patient's documentation about the present disease in order to inquire
was purposeful;

prepare questions - this creates an organized approach to the topic of the interview and makes
discussion understandable to both.

Second phase -

Listen carefully to the patient - this facilitates eye contact and allows the patient to feel the interest of the nurse in his : problems and everything that worries him.

An approving attitude contributes to an unbiased attitude towards the patient's lifestyle, his life values. Tune in to a friendly attitude, even if your views do not coincide with those of the patient.

Paraphrasing allows you to evaluate the received information using specific terms. For example: patient:" When I'm nervous, my head starts to hurt right here."

M / s: "Are you saying that after stress you have pain in the occipital region?"

Specify information. To do this, ask the patient to repeat what was said or
give an example.

During the discussion, do not deviate from the main topic of the questioning.

Sometimes it is appropriate to be silent - this gives the patient an opportunity to collect his thoughts, and
nurse to conduct visual observation.

Third stage - conclusion .

After questioning, the nurse must state the observation, i.e. inform the patient of the information received - this contributes to the establishment of feedback and makes it possible to find out how the patient perceived the information. The nurse needs to know and use the Interview Guidelines (Appendix 1)

The collection of inaccurate, incomplete information leads to an inaccurate identification of the patient's health care needs. Inaccurate data occurs when the nurse fails to gather all the necessary information or jumps to conclusions.

The main purpose of the interview is to compile a nursing history of the patient.

The medical history is information about the patient's health status, changes in his lifestyle (see Appendix 2).

Teaching aid for independent work of students of medical colleges and schools on the subject:

"Fundamentals of Nursing" Moscow 1999, pp. 26 - 27.

NURSING CASE HISTORY

Conducting a physical examination. To conduct a physical examination, a nurse must have the skills of examination, palpation, percussion, auscultation.

Collection of laboratory data.

This data supplements the information in the database.

A laboratory test is ordered by a doctor, a nurse explains how the patient should prepare, if necessary - how to collect urine, etc.

1.4. Data validation.

After collecting subjective and objective data, the data should be checked to ensure they are accurate.

The data of the actual examination and observation of the patient's behavior are verified by comparing them with the data obtained during the consultation with the doctor, medical staff, relatives.

To check that the symptoms are consistent with the medical diagnosis, medical reference books and specialist literature can be consulted.

Interview data can be verified immediately after the interview, when the m/s informs the patient of the information she has received. Any additions and corrections according to the patient should be added to the existing data.

1.5. Grouping data.

After collecting and verifying subjective and objective data, the m/s combines them into groups.

See annex 3.

In the process of dividing the data into groups, the m/s systematizes them and highlights those that should be paid attention to in the first place for proper treatment and a speedy recovery.

1.6. Documentation of information.

Documentation of the data is done after a full evaluation. Data is recorded thoroughly and accurately. All data on the patient's health status are recorded, even those that do not indicate a deviation in the state of health. Their significance may appear later, they can be used for comparison when the patient's condition changes.

Checking, sorting and grouping data are preliminary steps for nursing diagnosis.

You must be sure that your conversation will take place in a quiet, informal setting without distractions and will not be interrupted.

Use the most reliable source of information - if notmost patient, then his next of kin.

Use previous information about the patient's diagnoses (if known) to plan in advance what information to focus on and get the facts you need.

Before you begin, explain that the more you know about the patient and their family, the better care you can provide, which is why you ask a lot of questions.

Take short notes during the interview. Accurately record the dates, numbers and duration of hospitalizations and the onset of illnesses. Don't rely on memory. Do not try to keep notes in the form of complete sentences.

Be slow, show sincere interest and participation. Do not show irritation if the patient has a memory lapse.

Use eye contact properly. Observe the facial expression, "body language" of the patient. Do not keep your eyes on the patient and on the records for a long time.

Use neutral questions that will help the patient formulate their feelings. Use the patient's own words to clarify information.

For example: "When you say 'cutting pain', do you mean sudden and severe pain?" Use terminology that the patient understands. If you doubt that he understands you, ask him what he means by this or that concept.

For example: "Explain the feeling of nausea you are experiencing."

In order for the patient to feel the expediency of questioning, first of all ask about his complaints. Don't start with personal, sensitive questions.

Let the patient finish the sentence, even if he is overly verbose. Don't jump from topic to topic. If you need to repeat a question, rephrase it for better understanding.

Be sensitive to what the patient says. A simple nod, an assent, an approving look will help him continue the story.

Name the patient by I.O. Don't lose your professionalism. Be friendly and involved.

Speak clearly, slowly, distinctly.

Listen !

Nursing process. Objective examination

objective data - the nurse receives them with the help of the senses (vision, smell, perception by touch, etc.), observation, measurement, using instrumental and laboratory research methods, as well as additional research methods: percussion, palpation and auscultation.

patient examination: general - chest, torso, abdomen. Then - a detailed examination (of body parts by region): head, face, neck, torso, limbs, skin, bones, joints, mucous membranes, hairline .;

physical details: height, body weight, edema (localization);

facial expression: painful, puffy, anxious, without features, herds, wary, anxious, calm, indifferent, etc .;

state of consciousness: conscious, unconscious, clear, disturbed: confused, stupor, stupor, coma, other disorders of consciousness - hallucinations, delirium, depression, apathy, depression;

position of the patient in bed: active, passive, forced, functional;

Forced position during an attack of bronchial asthma

condition of the skin and visible mucous membranes: color, turgor, humidity, defects (rash, scarring, scratching, bruising (localization), swelling or pastiness, cyanosis, jaundice, dryness, peeling, pigmentation, etc .;

musculoskeletal system: deformation of the skeleton, joints, muscle atrophy, muscle tone (preserved, increased, decreased);

Body temperature: within the normal range, subfebrile, subnormal, febrile (fever);

respiratory system: NPV (characteristic of breathing: rhythm, depth, type), normal breathing is 16 - 18 - 20 breaths per minute, superficial, rhythmic;

HELL: on both arms, hypotension, normal, hypertension;

pulse: the number of pulse waves per minute, rhythm, filling, tension;

natural remedies: urination (frequency, amount, urinary incontinence, catheter, independently, urinal), stool (independent, regular, stool character, flatulence, stool incontinence, colostomy);

sense organs (hearing, sight, smell, touch, speech);

memory: saved, violated;

dream: the need to sleep during the day;

use of reserves: glasses, lenses, hearing aid, removable dentures;

movement ability: independently, with the help of something or someone;

ability to eat, drink: appetite, chewing disorder, nausea, vomiting, artificial nutrition.

Psychosocial assessment:

describe the manner of speaking observed behavior, emotional state, psychomotor changes in feeling;

socio-economic data are collected;

risk factors;

an assessment of the needs of the patient is carried out, the violated needs of the patient are determined.

Monitoring the patient's condition

When observing the patient's condition, the nurse should pay attention to:

on the state of consciousness;

position of the patient in bed;

facial expression;

the color of the skin and visible mucous membranes;

the state of the circulatory and respiratory organs;

functions of the excretory organs.

State of consciousness

clear mind - The patient answers questions clearly and specifically.

Confused mind - The patient answers questions correctly, not late.

Stupor - States of stunning, stupor, the patient answers questions late and meaninglessly.

Sopor - Pathological deep sleep, the patient is unconscious, reflexes are not preserved. A loud voice can bring him out of this state, but he soon falls back to sleep.

Coma - Complete depression of the functions of the central nervous system: consciousness is absent, muscles are relaxed, loss of sensitivity and reflexes.

Delusions and hallucinations - can be observed with severe intoxication (infectious diseases, severe pulmonary tuberculosis, pneumonia).

Facial expression

Corresponds to the nature of the course of the disease, it is influenced by the gender and age of the patient.

Distinguish:

the face of Hippocrates - with peritonitis ("acute abdomen"). Face - sunken eyes, pointed nose, pallor with cyanosis, drops of cold sweat;

puffy face with kidney diseases and other diseases - the face is swollen, pale

puffy face feverish face puffy eyes

Feverish face at high temperature - glitter of the eyes, flushing of the face;

Mitral "blush" - cyanotic cheeks on a pale face;

Bulging eyes, trembling of the eyelids - with hyperthyroidism, etc .;

Indifference, suffering, anxiety, fear, painful facial expression, etc.

Facial expression should be evaluated by a nurse, the changes of which she is obliged to inform the doctor.

Skin and visible mucous membranes

may be: pale, hyperemic, icteric, cyanotic (cyanosis), acrocyanosis. Pay attention to the rash, dry skin, areas of pigmentation, the presence of edema.

Assessment of the possibility of self-care (according to the patient's condition)

Satisfactory - the patient is active, facial expression without features, consciousness is clear, the presence of pathological symptoms does not interfere with remaining active.

Moderate condition - expresses complaints, there may be a forced position in bed, activity may increase pain, a painful facial expression, symptoms from systems and organs are expressed, the color of the skin is changed.

Severe condition - passive position in bed, active actions are difficult to perform, consciousness can be changed, facial expression is changed. Violations of the functions of the respiratory, cardiovascular and central nervous system are expressed.

Disturbed needs (underline) by Virginia Henderson:

breathe; 8 . maintain body temperature;

there is; 9 . to be healthy;

drink; 10. avoid danger;

allocate; 11 . move;

sleep, rest; 12 . communicate;

be clean; 13. have life values ​​- material and

dress, undress; spiritual;

14. play, study, work.

Self care assessment

The degree of independence of the patient in care is determined (the patient is independent, partially dependent, fully dependent, with the help of whom).

Having collected the necessary subjective and objective information about the patient's health status, the nurse should have a clear understanding before starting care planning.

Try to determine what is normal for a person, how he sees his normal state of health and what help he can provide himself.

Determine the person's impaired needs and care needs.

Establish effective (therapeutic) communication with the patient and involve him in cooperation.

Discuss care needs and expected outcomes with the patient.

Provide conditions in which nursing care takes into account the needs of the patient, shows care and attention to the patient.

Avoid new problems for the patient.

Symptoms of diseases of the digestive system

Nausea - a feeling of heaviness in the epigastric (epigastric) region (a harbinger of vomiting), may be central - not associated with diseases of the gastrointestinal tract and peripheral - associated with diseases of the gastrointestinal tract.

Vomiting is a reflex act, contraction of the walls of the stomach and diaphragm, followed by ejection of the contents outward (may be central - not associated with diseases of the gastrointestinal tract and peripheral - associated with diseases of the gastrointestinal tract). Vomiting can be food, acidic contents, bitter, rotten, vomiting obsessed with coffee thick, etc.

Vomiting the color of "coffee grounds" - a symptom of stomach bleeding

Belching is a weak contraction of the walls of the stomach, followed by the ejection of part of its contents into the oral cavity, it can be food, sour contents, bitter, rotten, air.

Heartburn is a burning sensation along the esophagus, the acidic contents of the stomach enter the alkaline environment of the esophagus, resulting in a neutralization reaction in the esophagus, hence the burning sensation, which occurs with diseases of the stomach and liver.

Hiccups - convulsive contraction of the diaphragm (may be of a nervous nature)

Diarrhea - frequent loose stools

Constipation - retention of stool for more than 48 hours.

Tenesmus - false urge to defecate or urinate

Colorless stool (white) - Symptom of jaundice (infectious or mechanical)

Melena-colored stools or "tarry" stools - black stools can be with gastrointestinal bleeding

Flatulence - accumulation of gases in the intestines (bloating), occurs with dyspepsia, after operations on the gastrointestinal tract.

Symptoms of diseases of the urinary organs

Dysuria - urination disorder

Pollakiuria - frequent urination

stranguria - difficulty urinating

Polyuria - daily diuresis more than 2 liters

Oliguria - daily diuresis less than 500 ml.

Ischuria - urinary retention due to the accumulation of urine in the bladder due to the impossibility of independent urination

Anuria - complete cessation of urine flow to the bladder

Uremia - the entry of nitrogenous slags into the blood (urinary blood) - the body self-poisons itself with its own decay products as a result of kidney failure

Hematuria (urine the color of meat slops) - blood in the urine

Albuminuria, proteinuria - protein in the urine

Glycosuria - sugar in the urine

Edema - accumulation of fluid in soft tissues

Anasarca - swelling of the whole body

Diuresis - the amount of urine allocated for a certain period of time (can be day, night, daily, and even hourly)

Water balance - the balance between the liquid drunk and the food eaten and the liquid excreted from the body per day (normally 1.5 - 2 liters)

Symptoms of respiratory diseases

Hydrothorax - accumulation of fluid in the chest (in the pleural cavity)

Pneumothorax - air entering the pleural cavity

Sputum is a pathological secret of the upper respiratory tract, it can be purulent, serous, mucous, bloody.

Hemoptysis - the appearance of streaks of blood in the sputum, a harbinger of pulmonary hemorrhage.

Pulmonary bleeding - the appearance of a coughblood

Apnea - stop breathing

Dyspnea - shortness of breath - a violation of the frequency, depth and rhythm of breathing, may beexpiratory dyspnea - breathing with difficulty exhaling, characteristic of bronchial asthma;inspiratory dyspnea -breathing with difficulty inhaling - occurs when a mechanical obstruction in the upper respiratory tract andmixed dyspnea - breathing with difficulty inhaling and exhaling.

Tachypnea - rapid breathing more than 20 breaths per minute.

Bradypnea - rare breathing less than 16 breaths per minute.

Arrhythmia is a violation of the rhythm.

Asphyxia - suffocation followed by respiratory arrest.

Asthma is an attack of suffocation (severe shortness of breath) of pulmonary or cardiac origin.

Pathological types of breathing

In a healthy person, breathing is rhythmic. If violations of the rhythm of breathing are repeated in a certain sequence, then such breathing is calledperiodic.There are the following types:

Cheyne–Stokes breathing - characterized by a gradual increase in the depth of breathing

which, having reached a maximum at 6-7 minutes of inspiration, and then in the same sequence decreases and goes into a pause from several seconds to 1 minute. It is observed in diseases of the brain, severe circulatory disorders, in coma and drug poisoning.

Breath of Biot - rhythmic deep respiratory movements alternating at regular intervals with respiratory arrest (from several minutes to 30 seconds).

Grokk's undulating breath - fluctuations in the depth of breathing, as with Cheyne-Stokes breathing, but instead of respiratory pauses, weak shallow breathing is noted.

"Kussmaul's Big Breath" - the rhythm of breathing is not disturbed, but the depth of breathing is significantly changed - deep and noisy breathing, one of the types of hematogenous shortness of breath. Occurs in diabetic, hepatic and other coma due to the accumulation of toxic acidic products in the blood as a result of metabolic disorders. May occur with cerebral hemorrhage (centrogenous dyspnea).

Remember ! If the patient has periodic breathing, call a doctor immediately!

Manipulation action algorithms

Stage 5 of the nursing process is continuous, occurring at each stage. The nurse evaluates the patient's health status, the effectiveness of planning, the nursing team, nursing care. The outcome process provides feedback to the nurse's performance; she goes back to each stage and analyzes the reasons for success or failure. A feature of this stage in gynecology is that the assessment is partially carried out without the participation of the patient. This applies, first of all, to the nursing process in the surgical period when general anesthesia is used, as well as to the early postoperative period. As in other areas of medicine, in gynecology, plans for nursing activities can be revised or radically changed depending on the patient's condition, the achievement or failure to achieve the goals and the characteristics of the diagnostic and therapeutic process.

Evaluating the effectiveness of nursing interventions is a multi-step process.

It is carried out:

• nurse
• patient
• patient's relatives
• head sister of the department
• department head
• hospital management

Formulation of the evaluation of the effectiveness of nursing interventions

Short term goal: The patient noted a decrease in the PRIORITY PROBLEM after 20-30 minutes. (up to 7 days) as a result of the joint actions of the doctor, nurse and patient. The goal was achieved.

Long term goal: The patient does not have a PRIORITY ISSUE by the end of 10-14 days as a result of the combined actions of the doctor, nurse and patient. The goal has been reached.

nursing care Nursing care includes the necessary medicines. inventory, tools, etc. to achieve the set goals.

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The nursing process consists of five steps. Each stage of the process is an essential step in solving the main problem - the treatment of the patient - and is closely interconnected with the other four stages.
The first stage: examination of the patient - the current process of collecting and processing data on the patient's health status (Fig. 1).

In "Notes on leaving" Florence Nightingale in 1859 | wrote; “The most important practical lesson that can! best given to nurses is to teach them what to watch for, how to watch, what symptoms indicate deterioration, what signs are! significant, which can be predicted, what signs indicate insufficient care, what is expressed in insufficient care. How relevant these words sound | these days!
The purpose of the survey is to collect, substantiate and interconnect! collect the information received about the patient in order to "create an information database about him, about his condition at the time of seeking help. The main role in the examination belongs to questioning. How skillfully * the nurse can arrange the patient for the necessary conversation, the information it receives will be so complete.
Survey data can be subjective or objective. The source of information is, first of all, the patient himself, who sets out his own assumptions about his state of health, this information is subjective. Only himself na | The patient can provide this kind of information. Subjective! ] data includes feelings and emotions expressed verbally and non-verbally.
Objective information - data that is received! as a result of observations and examinations conducted by a nurse. These include; anamnesis, sociological data (relationships, sources, environment in which the patient lives and works), developmental data (if it is a child), cultural information (scientific and cultural values), information about spiritual development! vitii (spiritual values, faith, etc.), psychological! data (individual character traits, self-esteem and ability to make decisions).
The source of information can be not only on-| sufferer, but also members of his family, work colleagues, friends, passers-by, etc. They give information; I tion and in the case when the victim is a child, a mentally ill person, a person in an unconscious state "or etc.
An important source of objective information are: data of the patient's physical examination (palpation, percussion, auscultation), measurement of blood pressure, pulse, respiratory rate; laboratory data.
The most objective and reliable are the observations and data of the nurse, obtained by her in the course of a personal conversation with the victim, after his physical examination and analysis of the available laboratory data. During the collection of information, the nurse establishes a “healing” relationship with the patient:

• determines the expectations of the patient and his relatives from the medical institution (from doctors, nurses);
• carefully acquaints the patient with the stages of treatment;
• begins to develop in the patient an adequate self-assessment of his condition;
• receives information that requires additional verification (information about infectious contact, previous diseases, operations performed, etc.);
• establishes and clarifies the attitude of the patient and his family to the disease, the relationship "patient - family".

Having information about the patient, using his trust and the location of his relatives, the nurse does not forget about the patient's right to confidentiality of information.
The end result of the first stage of the nursing process is the documentation of the information received and the creation of a patient database. The collected data are recorded in the nursing history of the disease in a certain form. Nursing medical history is a legal protocol-document of independent, professional activity of a nurse within her competence. The purpose of the nursing case history is to monitor the activities of the nurse, her implementation of the care plan and the doctor's recommendations, analyze the quality of nursing care and evaluate the professionalism of the nurse. And as a result - a guarantee of the quality of care and its safety.
As soon as the nurse has begun to analyze the data obtained during the survey, the second stage of the nursing process begins - problem identification

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of the patient and the formulation of the nursing diagnosis (Fig. 2). It should be noted that the purpose of this stage is complex and diverse.
It consists, firstly, in identifying problems,! arising in the patient as a kind of response reaction! bodily functions. The patient's problems are divided into cv-1 current and potential. Existing problems -1 are problems that the patient is currently experiencing. For example: a 50-year-old patient with a spinal injury is under observation. Victim-1 is on strict bed rest. Problems | of the patient that are currently bothering him - pain, stress, limited mobility, lack) of self-care and communication Potential problems are those that do not yet exist, but may appear over time.In our patient, potential problems are pressure sores, pneumonia, decreased muscle tone, irregular bowel movements, (constipation, fissures, hemorrhoids).
Secondly, in establishing the contributing factors! or causing these problems. Thirdly, in identifying the strengths of the patient, which would contribute to the prevention or resolution of his problems. |
Since the patient in most cases has several health problems, the nurse cannot start to solve them all at the same time. Therefore, in order to successfully resolve the patient's problems, the nurse must consider them taking into account priorities.
Priorities are classified as primary, intermediate and secondary. Patient problems that, if left untreated, could have a detrimental effect on the patient, have primary priority. Intermediate priority patient problems include non-extreme and non-life-threatening needs of the patient. Secondary priority issues are patient needs that are not directly related to disease or prognosis (Gordon, 1987).
Let's go back to our example and consider it in terms of priorities. Of the existing problems, the first thing that a nurse should pay attention to is pain, stress - the primary problems, arranged in order of importance. Forced position, restriction of movements, lack of self-care and communication are intermediate problems.
Of the potential problems, the primary ones are the likelihood of pressure sores and irregular bowel movements. Intermediate - pneumonia, decreased tone of the mouse. For each identified problem, the nurse outlines a plan of action for herself, not disregarding potential problems, as they can turn into obvious ones.
The next task of the second stage is the formulation of a nursing diagnosis.
(From the history of the emergence of nursing diagnosis: in 1973, the first scientific conference on the problem of classification of nursing diagnoses was held in the United States. Its objectives were to determine the functions of a nurse in the diagnostic process and develop a classification system for nursing diagnoses. In the same year, nursing diagnosis was included in the Standards of Nursing Practice published by the American Nursing Association (AAM).The North American Association for Nursing Diagnosis (NANAD) was founded in 1982. The purpose of this association was to "develop, improve, maintain a taxonomy, terminology of nursing diagnosis for general use by professional nurses "(Kim, McFarland, McLane, 1984). For the first time, the classification of nursing diagnoses was proposed in 1986 (McLane), in 1991 it was supplemented. The total list of nursing

diagnoses includes 114 main items, including: hyperthermia, pain, stress, social self-isolation, insufficient self-hygiene, lack of hygiene skills and sanitary conditions, anxiety, reduced physical activity, reduced individual ability to adapt and overcome stress reactions, excessive nutrition that exceeds the needs of the body , high risk of infection, etc.).
Currently, there are many definitions of nursing diagnosis. These definitions arose as a result of the recognition of nursing diagnosis as part of the professional activity of a nurse. In 1982, a new definition appeared in the textbook on nursing by the authors Carlson, Kraft and Maklere: "Nursing diagnosis is a patient's health condition (current or potential), established as a result of a nursing examination and requiring intervention from the nurse."
It should be recognized that there is verbosity and inaccuracy in the diagnostic language in nursing diagnosis, and this, of course, limits its use by nurses. At the same time, without a unified classification and nomenclature of nursing diagnoses, nurses will not be able to use nursing diagnosis in practice and communicate with each other in a professional language that is understandable to everyone.
It should be noted that, unlike a medical diagnosis, a nursing diagnosis is aimed at identifying the body's responses to a disease (pain, hyperthermia, weakness, anxiety, etc.). A medical diagnosis does not change unless a medical error has been made, but a nursing diagnosis can change every day and even throughout the day as the body's response to illness changes. In addition, the nursing diagnosis may be the same for different medical diagnoses. For example, a nursing diagnosis of "fear of death" may be in a patient with acute myocardial infarction, in a patient with a neoplasm of the breast, in a teenager whose mother has died, etc.
Thus, the task of nursing diagnostics is to establish all current or possible future deviations from a comfortable, harmonious state, to establish what is most burdensome for the patient at the moment, is the main thing for him, and try to correct these deviations within his competence.
The nurse does not consider the disease, but the patient's response to the disease and their condition. This reaction can be: physiological, psychological, social, spiritual. For example, in bronchial asthma, the following nursing diagnoses are likely: ineffective airway clearance, high risk of suffocation, reduced gas exchange, despair and hopelessness associated with a long-term chronic illness, lack of self-hygiene, a sense of fear.
Please note that there can be several nursing diagnoses for one disease at once. The doctor stops an attack of bronchial asthma, establishes its causes, prescribes treatment, and teaching the patient to live with a chronic disease is the task of a nurse.
Nursing diagnosis can refer not only to the patient, but also to his family, the team in which he works or studies, and even to the state. Since the realization of the need for movement in a person who has lost his legs, or self-care in a patient who is left without arms, in some cases cannot be realized by the family. To provide the victims with wheelchairs, special buses, lifts to railway cars, etc., special state programs are needed, that is, state assistance. Therefore, in the nursing diagnosis of "social isolation of the patient" both family members and the state can be guilty.
After the examination, diagnosis and determination of the patient's primary problems, the nurse formulates the goals of care, expected results and terms, as well as methods, methods, techniques, i.e. nursing actions that are necessary to achieve the goals. She moves on to the third stage of the nursing process - nursing care planning (Fig. 3).
The care plan coordinates the work of the nursing team, nursing care, ensures its continuity, helps to maintain links with other specialists and services. A written plan for patient care reduces the risk of incompetent care. This is not only a legal document of the quality of nursing care, but also

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A document that identifies economic costs as it specifies the materials and equipment i required to provide nursing care. This "allows you to determine the need for those resources that are used most often and effectively in a particular medical department and institution. The plan necessarily provides for the participation of the patient and his family in the care process. It includes criteria for evaluating care and expected results.
Setting goals for nursing care is important for the following reasons. It provides direction in the conduct of individual nursing care, nursing activities and is used to determine the degree of effectiveness of these activities. Setting goals for care must meet certain requirements: goals and objectives must be realistic and achievable, must have specific deadlines for achieving each task (the principle of “measurability”). It should be noted that in setting care goals, as well as in their implementation, the patient (where possible), his family, as well as other specialists are involved.
Each goal and expected result should be given time for evaluation. Its duration depends on the nature of the problem, the etiology of the disease, the general condition of the patient and the established treatment. There are two types of goals: short-term and long-term. Briefly-(

urgent - are goals that must be completed in a short period of time, usually 1-2 weeks. They are placed, as a rule, in the acute phase of the disease. These are targets for urgent nursing care.
Long-term - are goals that are achieved over a longer period of time (more than two weeks). OII are usually aimed at preventing recurrence of diseases, complications, their prevention, rehabilitation and social adaptation, and acquiring knowledge about health. The fulfillment of these goals most often falls on the period after the discharge of the patient. It must be remembered that if long-term goals or objectives are not defined, then the patient does not have, and in fact is deprived of, planned nursing care at discharge.
During the formulation of goals, it is necessary to take into account: action (performance), criterion (date, time, distance, expected result) and conditions (with the help of what or by whom). For example: a nurse must teach a patient to inject himself with insulin for two days. Action - to inject; time criterion - within two days; condition - with the help of a nurse. To successfully achieve the goals, it is necessary to motivate the patient and create a favorable environment for their achievement.
In particular, an approximate individual care plan for our victim might look like this:

• solution of existing problems; administer an anesthetic, relieve the patient's stress with the help of a conversation, give a sedative, teach the patient to serve himself as much as possible, that is, help him adapt to the forced state, talk more often, talk with the patient;
• solving potential problems: strengthen skin care measures to prevent pressure ulcers, establish a diet with a predominance of foods rich in fiber, dishes with a reduced content of salt and spices, conduct regular bowel movements, exercise with the patient, massage the muscles of the limbs, exercise with the patient breathing exercises, to teach family members how to care for the victim;
• identification of possible consequences: the patient must be involved in the planning process.

The preparation of a care plan requires the existence of standards of nursing practice, that is, the implementation of the minimum quality level of service that provides professional care for the patient. It should be noted that the development of nursing practice standards, as well as criteria for evaluating the effectiveness of nursing care, nursing medical history, nursing diagnoses for Russian healthcare is a new, but extremely important matter.
After defining the goals and objectives of care, the nurse draws up the actual care plan for the patient - a written care guide. The patient care plan is a detailed listing of the nurse's special actions needed to achieve nursing care, which is recorded in the nursing record.
Summing up the content of the third stage of the nursing process - planning, the nurse should clearly present the answers to the following questions:

• what is the purpose of care?
• Who do I work with, what is the patient as a person (character, culture, interests, etc.)?
• what is the patient's environment (family, relatives), their attitude towards the patient, their ability to provide assistance, their attitude to medicine (in particular, to the activities of nurses) and to the medical institution in which the victim is being treated?
• What are the tasks of the nurse in achieving the goals and objectives of patient care?
• what are the directions, ways and methods of achieving goals and objectives?
• what are the possible consequences?

Having planned activities for the care of the patient, the sister performs them. This will be the fourth stage of the nursing process - the implementation of the nursing intervention plan (Fig. 4). Its purpose is to provide appropriate care for the victim, that is, to assist the patient in fulfilling the needs of life; training and counseling, if necessary, the patient and his family members.
There are three categories of nursing intervention: independent, dependent, interdependent. The choice of category is based on the needs of the patient.

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Independent nursing intervention refers to actions carried out by a nurse on her own initiative, guided by her own considerations, without a direct request from the doctor or instructions from other specialists. For example: training the patient in self-care skills, relaxing massage, advice to the patient about his health, organizing the patient's leisure time, teaching family members how to care for the sick, etc.
Dependent nursing intervention is carried out on the basis of written prescriptions of a doctor and under his supervision. The nurse is responsible for the work performed. Here she acts as a sister performer. For example: preparing the patient for a diagnostic examination, performing injections, physiotherapy, etc.
According to modern requirements, the nurse should not automatically follow the instructions of the doctor (dependent intervention). IN THE CONDITIONS of guaranteeing the quality of medical care, its safety for the patient, the nurse should be able to determine whether this prescription is necessary for the patient, whether the dose of the drug is correctly selected, whether it does not exceed the maximum single or daily dose, whether
contraindications, is this drug compatible | remedy with others, whether the route of administration is chosen correctly. I The fact is that the doctor may get tired, he may lose attention, finally, due to a number of objective or | subjective reasons, he can make a mistake. Therefore, in the interests of the safety of medical care for [the patient, the nurse must know and be able to clarify the need for certain prescriptions, the correct dosage of medicines, etc. It must be remembered that a nurse who performs an incorrect or unnecessary prescription is professionally incompetent and is just as responsible for the consequences of the error as the one who made the appointment.
Interdependent nursing intervention involves the joint activities of a nurse with a doctor and other specialists (physiotherapist, nutritionist, exercise therapy instructor, social care workers). The responsibility of the nurse is equally great for all types of intervention.
The nurse carries out the planned plan, applying several methods of care: assistance related to daily life needs, care for achieving therapeutic goals, care for achieving surgical goals, care for facilitating the achievement of health care goals (creating a favorable environment, stimulating and motivating the patient) etc. Each of the methods includes theoretical and clinical skills. The patient's need for help can be temporary, permanent and rehabilitating. Temporary assistance is designed for a short period of time when there is a shortage of self-care. For example, with dislocations, minor surgical interventions, etc. The patient needs constant help throughout his life - with amputation of limbs, with complicated injuries of the spine and pelvic bones, etc. Rehabilitating care is a long process, an example of this is exercise therapy, massage, breathing exercises, I conversation with the patient.
Among the methods for implementing patient care activities, a conversation with the patient and advice that a nurse can give in a necessary situation play an important role. Advice is emotional, intellectual and psychological help that helps

the sufferer to prepare for present or future changes arising from stress, which is always present in any disease and facilitates interpersonal relationships between the patient, family, and medical personnel. Patients in need of advice include those who need to adapt to a healthy lifestyle - stop smoking, lose weight, increase their degree of mobility, etc.
Carrying out the fourth stage of the nursing process, the nurse carries out two strategic directions:

• monitoring and monitoring the patient's response to doctor's appointments with fixing the results in the nursing history of the disease;

• observation and control of the patient's response to the performance of nursing actions related to the nursing diagnosis and recording the results in the nursing history of the disease.

At this stage, the plan is also adjusted if the patient's condition changes and the goals set are not realized. The implementation of the planned action plan disciplines both the nurse and the patient. Often a nurse works under time pressure, which is associated with understaffing of nursing staff, a large number of patients in the department, etc. Under these conditions, the nurse must determine: what should be done immediately; what should be carried out according to the plan; what can be done if time remains; what can and should be transferred by shift.
The final stage of the process is the assessment of the effectiveness of the nursing process (Fig. 5). Its purpose is to assess the patient's response to nursing care, analyze the quality of care provided, evaluate the results and summarize. Evaluation of the effectiveness and quality of care should be carried out by the senior and chief nurses constantly and by the nurse herself in the order of self-control at the end and at the beginning of each shift. If there is a nursing team, the evaluation is carried out by a nurse who acts as a coordinating nurse. A systematic assessment process requires the nurse to be knowledgeable and analytical in comparing achieved results with those expected. If the tasks are completed and the problem is solved, medical

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The nurse must certify this by making an appropriate entry in the nursing record, date and signature.
At this stage, the patient's opinion about the nursing activities carried out is important. The assessment of the entire nursing process is carried out if the patient is discharged, if he was transferred to another medical institution, if he died, or in case of long-term follow-up.
If necessary, the nursing action plan is reviewed, interrupted or modified. When the intended goals are not being achieved, the assessment provides an opportunity to see the factors that hinder their achievement. If the end result of the nursing process results in failure, then the nursing process is repeated sequentially to find the error and change the nursing intervention plan.
Thus, the assessment of the results of nursing intervention enables the nurse to establish the strengths and weaknesses in her professional activities.
It may seem that the nursing process and the nursing diagnosis are formalism, “sticky papers”. But the fact is that behind all this is a patient who is right
In a new state, effective, high-quality and safe medical care, including nursing, must be guaranteed. The conditions of insurance medicine imply, first of all, the high quality of medical care, when the measure of responsibility of each participant in this care must be determined: the doctor, the nurse and the patient. Under these conditions, rewards for success and penalties for mistakes are assessed morally, administratively, legally, and economically. Therefore, every action of a nurse, every stage of the nursing process is recorded in the nursing history of the disease - a document reflecting the qualifications of the nurse, the level of her thinking, and therefore the level and quality of the care she provides.
Undoubtedly, and world experience testifies to this, the introduction of the nursing process into the work of medical institutions will ensure the further growth and development of nursing as a science, and will allow nursing in our country to take shape as an independent profession.