Chapter 5.

NURSING PROCESS:

INDIVIDUAL APPROACH TO THE PATIENT

Issues covered:

5.1. Definition of the nursing process.

5.2. Patient examination.

5.3. Identifying patient problems.

5.4. Nursing care planning.

5.5. Implementation of the nursing intervention plan.

5.6. Assessment of nursing performance.

Key concepts: nursing process, Maslow's needs, objective information about the patient, "therapeutic" relationship, nursing medical history, nursing diagnosis, existing problems, potential, nursing care planning, goals, individual plan, independent intervention, dependent intervention, interdependent intervention, methods of care, rules of care, need for help, types of assessment of nursing activities.

One of the basic and integral concepts of modern American and Western European models of nursing is the nursing process. This reform concept was born in the USA in the mid-50s and over the subsequent decades of its testing in clinical settings has fully proven its feasibility. Currently, the nursing process is the basis of nursing care.

Based on the results of a nursing study conducted by the WHO Regional Office for Europe: “The essence of nursing is caring for people, and the way a nurse provides this care represents the essence of the nursing process. This work should not be based on intuition, but on a thoughtful and formed approach, designed to meet needs and solve problems...”

The nursing process is the method by which nurses carry out their responsibilities in providing care to patients, scientifically based and carried out in practice. The nursing process brings a new understanding of the role nurse in practical healthcare, requiring from it not only the presence of good technical training, but also the ability to creatively relate to patient care, the ability to work with the patient as a person, and not as a nosological unit, an object of “manipulation technique”. Constant presence and contact with the patient makes the nurse the main link between the patient and the outside world. The biggest winner in this process is the patient. The outcome of the disease often depends on the relationship between the nurse and the patient and their mutual understanding.

What does the nursing process provide for practice? What are his goals?

1. Identifies the patient's specific care needs.

2. From a number of existing needs, he identifies priorities for care and the expected results of care; in addition, he predicts its consequences.

3. Determines a plan of action, a strategy aimed at meeting the needs of the patient.

4. Evaluates the effectiveness of the work performed and the effectiveness of nursing interventions.

5. Guarantees quality of care that can be monitored.

The content of the definition of the nursing process is a logically based structure of thinking and actions of a nurse, aimed at organizing nursing practice. The nursing process is an evidence-based method for systematically identifying a patient's situation and the problems that arise in that situation in order to construct a plan of care that is acceptable to both the patient and the nurse.

American psychologist Abraham Maslow studied the motivations for human behavior and his life and expressed his generalizations in the form of a well-known pyramid (Fig. 1).

He called a need the lack of what is essential for human health and well-being. He identified 14 basic vital (in his opinion) human needs (eat, drink, breathe, excrete, be healthy, be clean, dress and undress, avoid danger, maintain body temperature, sleep and rest, move, communicate, have life values, play, study and work) and arranged them in order of subordination (from lower physiological to higher psychosocial) in the form of a pyramid.

Thus, the main goal of the nursing process- maintaining and restoring the patient’s independence in meeting 14 basic human needs in order to provide the patient with an acceptable quality of life, even in a state of illness. This task will be impossible if we do not see in the patient a person who has not only physical and biological health problems, but also psychological, social, and spiritual ones.

The nurse, within the limits of her competence, must help the patient in obtaining the “missing”. Considering each person through the prism of basic human needs, the nurse decides how she can help the patient in correction, restoration of impaired needs, in his personal and social adaptation to the disease, in overcoming social adaptation.

Thus, in order to organize quality care, the nurse, based on the collected and carefully analyzed information about her patient, must determine his violated needs and the problems arising in connection with this, both for the patient himself and for his family or the team in which he located. If we remember that the definition in Greek is “diagnosis,” then the nurse diagnoses the violated needs and the problems that arise in connection with this. To do this, the nurse evaluates the following groups of parameters:

¨ state of the main functional systems of the body;

¨ emotional and intellectual background, range of adaptation to stress;

¨ sociological data;

Rice. 1. Pyramid of human needs.

¨ environmental data in terms of positive and negative impacts.

Since the nursing process is a cyclical process, its organizational structure consists of several successive stages: nursing examination of the patient, diagnosing his condition (identifying needs and identifying problems), planning care aimed at meeting identified needs (problems), implementing a plan for the necessary nursing interventions and evaluation of the results obtained and correction if necessary.

Benefits of implementation methodology nursing process for nursing education and nursing practice:

1. Systematic and individual approach to providing nursing care.

2. Active participation of the patient and family in planning and providing care.

3. Possibility of widespread use of professional standards.

4. Effective use of time and resources that are aimed at solving the basic needs and problems of the patient.

5. The versatility of the method.

6. The patient receives comprehensive and high-quality medical care.

7. The quality of care provided and the professionalism of the nurse are documented.

8. Demonstrates (once documented) the level of professional competence, responsibility and reliability of the nursing service and medical care.

9. Guarantees the safety of medical care.

As a systematic method of problem solving, the nursing process can be applied in all areas practical activities. It encourages nurses to gain greater autonomy and responsibility, which supports the expansion of their role, promotes collaboration among health care professionals and stimulates professional growth.

The nursing process consists of five stages. Each stage of the process is an essential stage in solving the main problem - treating the patient, and is closely interrelated with the other four stages.

First stage: examination of the patient - the current process of collecting and processing data on the patient’s health status (Diagram 1).

In her Nursing Notes, Florence Nightingale wrote in 1859: “The most important practical lesson that can be given to nurses is to teach them what to watch, how to watch, what symptoms indicate deterioration, what signs are significant, what it is possible to predict what signs indicate insufficient care, how insufficient care is expressed.” How relevant these words sound today!

The purpose of the examination is to collect, substantiate and interconnect the information received about the patient in order to create an information database about him and his condition at the time of seeking help. The main role in the survey belongs to questioning. How skillfully the nurse can position the patient for the necessary conversation, the information she receives will be complete.

Survey data can be subjective and 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 the patient himself can provide this kind of information. Subjective data includes feelings and emotions expressed verbally and non-verbally.

Objective information - data obtained as a result of observations and examinations conducted by a nurse. These include:

1. Anamnesis collection, including:

– the history of the occurrence of a particular problem in the patient’s health;

– sociological data (relationships, financial status, sources, environment in which the patient lives and works);

– development data (if this is a child);

– - intellectual data (speech, memory, level of communication, intelligence, etc.);

– cultural data (ethnic and cultural values);

– data on spiritual development (spiritual values, faith, habits, etc.);

– psychological data (individual character traits, behavior, mood, self-esteem and decision-making ability).

A patient who is willing to answer questions provides the most accurate information about lifestyle characteristics, current and past illnesses, perceived symptoms and existing problems. The source of information can be not only the victim, but also his family members, work colleagues, friends, passers-by, etc. They also provide information in cases where the victim is a child, a mentally ill person, an unconscious person, etc. In extreme situations, they may be the only available sources from which information can be obtained about the characteristics of the disease, medications taken, allergic reactions, etc. The information received is like the starting point of the information base about the patient.

Scheme 15

Due to the fact that assessing the patient's condition is a continuous process, the nurse must maintain communication with other members of the medical care team (doctors, orderlies, auxiliary nurses, laboratory assistants, etc.).

During data collection, the nurse establishes a “therapeutic” relationship with the patient:

· determines the expectations of the patient and his relatives from the medical institution (from doctors, nurses - what do they expect, what do they hope for, what will they help with?);

· carefully introduces the patient to the stages of treatment;

· the patient begins to develop an adequate self-assessment of his condition;

· receives information that requires additional verification (information about infectious contact, tuberculosis, benefits, surgery performed, etc.);

· establishes and clarifies the attitude of the patient and his family to the disease, the “patient-family” relationship.

As necessary, social service workers are involved to obtain additional information about the patient, and now often representatives of the spiritual sphere, lawyers, etc. All of them are potential sources of information.

In some cases, you can obtain the necessary information from medical documentation (outpatient card, extract from medical history, sick leave, documents from the place of work, study, medical care provided, etc.) about the patient’s health status in the past, about the methods of his treatment, about the results achieved. Reviewing specialized medical literature helps the nurse improve her educational level on the required issue, supplement and complete the information database about the patient.

2. Physical examination of the patient:

– palpation;

– percussion;

– auscultation;

– blood pressure measurement, etc.

3. Laboratory research.

The most objective and reliable are the observations and data of the nurse, obtained during a personal conversation with the victim, after his physical examination and available laboratory data.

Having information about the patient, taking advantage of his trust and the trust of his relatives, the nurse remembers 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 obtained and the creation of a database about the patient. The collected data is recorded in the nursing medical history using a specific form. A nursing medical history is a legal protocol document of the independent, professional activities of a nurse within the framework of her competence. The purpose of the nursing medical history is to monitor the activities of the nurse, her implementation of the care plan and doctor’s recommendations, analyze the quality of nursing care and assess the professionalism of the nurse. And as a result, a guarantee of the quality of care and its safety.

Once the necessary patient information has been collected, it should be analyzed to determine the patient's self-care capabilities, home care, and need for nursing intervention. This requires a certain level of knowledge about the physical, psychological and social functioning of humans and knowledge of basic nursing knowledge.

As soon as the nurse has begun to analyze the data obtained during the examination, the second stage of the nursing process begins (Diagram 2) - identifying the patient’s problems and formulating a nursing diagnosis. It should be noted that the goal is complex and diverse. It consists, firstly, in identifying the problems that arise in the patient as a kind of response of the body. The patient's problems are divided into existing and potential. Existing problems are problems that are bothering the patient at the moment. For example: a 50-year-old patient with a spinal injury is under observation. The victim is on strict bed rest. The patient's current problems are pain, stress, limited mobility, lack of self-care and communication. Potential problems- those that do not yet exist, but may appear over time. The sources of such problems can be: the environment, the patient’s current and existing chronic diseases, ongoing medical treatment and nursing care, hospital environment, personal problems, etc. In our patient, potential problems are: the appearance of bedsores, pneumonia, decreased muscle tone, irregular bowel movements (constipation, fissures, hemorrhoids). Secondly, in identifying the factors contributing to or causing the development of these problems; and thirdly, in identifying the patient's strengths that would help prevent or resolve his problems. Since the patient in most cases has several health problems, the nurse cannot begin to solve them at the same time. Therefore, to successfully resolve the patient's problems, the nurse must consider them based on priorities. Priorities are classified as primary, intermediate and secondary. Nursing diagnoses that, if left untreated, could have a detrimental effect on the patient are given first priority. Intermediate priority nursing diagnoses include non-extreme and non-life-threatening needs of the patient. Secondary priority nursing diagnoses are patient needs that do not have direct relationship to disease or prognosis (Gordon, 1987).

Scheme 16

Let's return to our example and consider it taking into account priorities. Of the existing problems, the first thing the nurse should pay attention to is pain, stress - the primary problems, arranged in order of importance. Forced positioning, limitation of movements, lack of self-care and communication are intermediate problems.

Of the potential problems, the primary ones are the likelihood of bedsores and irregular bowel movements. Intermediate - pneumonia, decreased muscle tone. For each identified problem, the nurse outlines an action plan, not ignoring potential problems, as they can turn into obvious ones.

After examining, establishing a diagnosis and identifying the patient’s primary problems, the nurse formulates the goals of care, expected results and timing, 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 - planning nursing care(Scheme 3).

Nursing care planning consists of four steps:

· identifying types of nursing interventions;

· discussing the plan of care with the patient;

· defining desired care outcomes;

· reviewing the plan with other members of the care team to ensure continuity of care.

The care plan coordinates the work of the nursing team, nursing care, ensures its continuity, and helps maintain connections with other specialists and services. A written patient care plan reduces the risk of incompetent care. It is not only a legal document of the quality of nursing care, but also a document that allows for the determination of economic costs, since it specifies the materials and equipment needed to perform nursing care. This allows us to determine the need for those materials and equipment that are used most often and effectively in a particular medical department and institution. The plan must include the participation of the patient and his family in the care process. It includes criteria for assessing care and expected outcomes. Setting goals for nursing care is necessary for the following reasons: it provides direction for individual nursing care, nursing actions and is used to determine the degree of effectiveness of these actions. Setting goals for care must meet certain requirements: goals and objectives must be realistic and achievable, and must have specific deadlines for achieving each goal (the “measurable™” principle). It should be noted that the patient (where possible), his family, as well as other professionals participate in setting goals of care, as well as in their implementation. Time should be allocated for evaluation for each goal and each expected result. This time depends on the nature of the problem, its etiology, general condition patient and prescribed treatment. There are two types of goals: short-term and long-term. Short-term goals are goals that must be achieved in a short period of time, usually 1-2 weeks, they are usually set in the acute phase of the disease. These are the goals for acute nursing care. Long-term goals are those that are achieved over a longer period of time, i.e. more than two weeks. They are usually aimed at preventing relapses of diseases, complications, their prevention, rehabilitation and social adaptation, and acquiring knowledge about health. Achievement of these goals most often occurs after the patient is discharged. It must be remembered that if long-term goals or objectives are not defined, then the patient does not have and is essentially deprived of planned nursing care upon discharge.

There are seven directions for defining goals and expected results:

1. Patient-centered factors which reflect the patient's response to nursing intervention.

2. Single factors - When each goal or expected outcome must be output to the patient's response, only then will the nurse be able to accurately determine whether the expected outcome has been achieved.

3. Observable factors when, through observation, a nurse notes changes in the patient’s health status.

4. Measuring factors (accurate measurement of physiological indicators of the patient’s health status and their specific description).

5. Time-limited factors. For each goal and each expected outcome, a time frame must be established before the expected response to nursing intervention occurs.

6. Joint factors. Determination of goals and expected results jointly with the patient.

7. Realistically feasible factors. Brief, achievable goals and expected results give the patient and nurse a feeling that treatment will be completed soon.

When writing goals, it is necessary to take into account: action (execution), criterion (date, time, distance, expected result) and conditions (with the help of what/whom). For example: The nurse should teach the client to self-administer insulin injections for two days. Action - give injections; time criterion - within two days; condition - with the help of a nurse. To successfully achieve goals, it is necessary to motivate the patient and create favorable environment to achieve them.

Scheme 17

In particular, sample individual care plan our victim may look like this:

1. Solution to existing problems: administer an anesthetic, relieve the patient’s stress state through conversation, give a sedative, teach the patient how to care for himself as much as possible, that is, help him adapt to the forced state, talk more often, talk with the patient.

2. Solution potential problems: strengthen skin care measures to prevent bedsores, establish a diet with a predominance of foods rich in fiber, dishes with a reduced content of salt and spices, carry out regular bowel movements, engage in physical exercise with the patient, massage the muscles of the limbs, engage in breathing exercises with the patient, train family members to care for the victim.

3. Definition possible consequences: The patient must be involved in the planning process.

Drawing up a plan of care involves standards of nursing practice, i.e. the minimum level of service that provides quality patient care. It should be noted that the development of standards of nursing practice, as well as criteria for assessing the effectiveness of nursing care, nursing medical history, nursing diagnoses, is a new but extremely important matter for Russian healthcare.

After formulating the goals and objectives of care, the nurse draws up the actual patient care plan - a written care guide, which is a detailed listing of the special actions of the nurse necessary to achieve nursing care, which is recorded in the nursing medical record.

Summarizing the content of the third stage of the nursing process - planning, the nurse must clearly represent the answers to the following questions:

1. What is the purpose of care?

2. Who am I working with, what is the patient like as a person (character, culture, interests, etc.)?

3. What is the patient’s environment (family, relatives), their attitude towards the patient, their ability to provide assistance, their attitude towards medicine (in particular, towards the activities of nurses) and towards the medical institution in which the victim is being treated?

4. What are the nurse's roles in achieving patient care goals and objectives?

5. What are the directions, ways and methods of achieving goals and objectives?

6. What are the possible consequences?

Having planned activities to care for the patient, the nurse carries them out. It will be fourth stage of the nursing process- implementation of the nursing intervention plan (Diagram 4). Its purpose is to provide appropriate care for the victim, that is, to assist the patient in fulfilling the needs of life; education and counseling, if necessary, for the patient and his family members.

Implementation of the plan of care requires the following functions (LEMON, 1996):

· coordinating and implementing nursing care in accordance with the agreed plan of care;

· registration of planned and unplanned care and assistance provided and not provided.

Choosing the most effective and appropriate intervention depends on:

· accurately determining the patient's needs;

· understanding that any medical diagnosis and treatment may affect the final outcome;

· knowledge of possible nursing intervention options to solve a specific problem.

There are three categories of nursing interventions: independent, dependent, interdependent. The choice of category is based on the needs of the patient.

Independent nursing intervention involves actions carried out by the nurse on her own initiative, guided by her own considerations, without direct demands from the doctor or instructions from other specialists. For example: teaching the patient self-care skills, relaxing massage, advice to the patient regarding his health, organizing the patient’s leisure time, teaching family members how to care for the patient, etc.

Scheme 18

Dependent Nursing Intervention performed on the basis of written instructions from a doctor and under his supervision. Here she acts as a sister performer. For example: preparing a patient for a diagnostic examination, performing injections, physiotherapeutic procedures, etc.

According to modern requirements, the nurse should not automatically follow the doctor’s instructions (dependent intervention). In conditions of guaranteeing the quality of medical care and its safety for the patient, the nurse must 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 are taken into account, whether the drug is compatible with others, whether the route of administration is chosen correctly. The fact is that the doctor may get tired, his attention may decrease, and finally, due to a number of objective or subjective reasons, he may 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 and the correct dosages medicines etc. It must be remembered that a nurse who carries out an incorrect or unnecessary prescription is professionally incompetent and is as responsible for the consequences of the error as the one who prescribed it.

Interdependent nursing intervention involves the joint activities of a nurse with a doctor and other specialists - a physiotherapist, nutritionist, exercise therapy instructor, and social assistance workers.

The nurse's responsibility is equal for all types of interventions.

The nurse carries out the plan using several methods of care: care related to daily living needs, care to achieve therapeutic goals, care to achieve surgical goals, care to facilitate the achievement of health care goals (creating a favorable environment, stimulation and motivation of the patient), etc. Each method includes theoretical and clinical skills.

Patient Care Rules (cognitive, interpersonal and psychomotor skills):

· cognitive skills include knowledge about nursing. The nurse must know the reason for each intervention and the types of body responses to these interventions;

· interpersonal skills - the nurse must be able to communicate with the patient, his family and other members of the medical team, i.e., have communication skills and a high culture of communication;

· psychomotor skills or technical include immediate patient care needs. For example, personal hygiene of the patient, performing injections, etc.

The patient's need for help can be temporary, permanent or rehabilitative. Temporary assistance is designed for a short period of time when there is a lack of self-care, for example, with sprains, minor surgical interventions ah, etc. Constant help The patient needs it throughout his life - with amputation of limbs, with complicated injuries of the spine and pelvic bones, etc. Rehabilitative care is a long-term process; examples include exercise therapy, massage, breathing exercises, and conversation with the patient.

Among the methods of implementing patient care activities, a conversation with the patient and advice that a nurse can give in the necessary situation play an important role. Advice is emotional, intellectual and psychological assistance that helps the victim prepare for present or upcoming changes that arise due to stress, which is always present in any disease and facilitates interpersonal relationships between the patient, family, and medical personnel. Patients in need of advice also include those who need to adapt to healthy image life - quit smoking, lose weight, increase mobility, etc.

At this stage, the patient acts as an accomplice in the process of providing nursing care, and is not a passive observer.

Carrying out the fourth stage of the nursing process, the nurse carries out two strategic directions:

1. Observation and control of the patient’s reaction to the doctor’s prescriptions, recording the results obtained in the nursing medical history.

2. Observe and control the patient's response to the nursing care activities associated with the nursing diagnosis and record the findings in the nursing record.

At this stage, the plan is adjusted if the patient’s condition changes and the set goals are not realized.

Fulfilling the intended action plan disciplines both the nurse and the patient.

Often, a nurse works under time pressure, which is associated with an understaffing of nursing staff, a large number patients in the department, etc. In these conditions, the nurse must determine: what needs to be done immediately; what should be carried out according to plan; what can be done if time remains; what can and should be conveyed during the shift. Implementing a nursing care plan does not mean that you should adhere to any particular system of delivery. It is at this stage that all stages of the nursing process “come to life”, and the results of planning nursing care are clearly manifested in interaction with the patient. Critical thinking and personal approach, which are necessary conditions when preparing a care plan, have the same important and for its implementation. Although a nursing care plan has already been developed in detail, this does not mean that nursing care will be provided automatically. It is during the implementation of planned actions that the need for professional judgment and critical thinking is greatest, since the plan of nursing interventions may need to be revised, and the nurse will have to constantly evaluate and re-evaluate her actions during the care process. At this stage, it is possible to delegate assistance to other members of the medical care team. It is necessary to provide continuum of care (e.g., throughout the day) and to ensure that the varying levels of knowledge and skills within the nursing team are utilized as effectively as possible.

Responsibility for providing nursing care usually rests with the nurse who assessed the patient's condition and initiated the development of the care plan.

The final stage of the process - assessment of the effectiveness of the nursing process (Diagram 5). Its purpose is to evaluate the patient's response to nursing care, evaluate the quality of care provided, compare progress and results achieved with planned nursing outcomes, evaluate the effectiveness of planned nursing interventions, further evaluation and planning if expected results are not achieved, critically analyze all stages of the nursing process and making the necessary amendments. Process final assessment necessary to complete the nursing process and to analyze:

– successful progress of the patient towards planned goals or vice versa;

– achieving the desired results or vice versa;

– need for additional assistance.

Scheme19

The final assessment is also important to know the impact various types nursing intervention to achieve specific results and about the application in practice of the various stages of the nursing process and the use of the selected model of nursing care.

According to the World Health Organization, summative assessment consists of: “... the examination and decision-making in terms of certain criteria relevant to the stated goal. The summative assessment provides feedback that can be used to determine the individual's other needs. The purpose of the summative assessment is to determine the outcome, i.e. the patient's condition achieved as a result of nursing intervention determined by the goals of nursing care.”

Evaluation of the effectiveness and quality of care should be carried out by the senior and chief nurses constantly and by the nurse herself as self-monitoring at the end and at the beginning of each shift. If a team of nurses is working, the assessment is carried out by a nurse who serves as a nurse coordinator. A systematic assessment process requires the nurse to have knowledge and the ability to think analytically when comparing achieved results with expected ones. If the assigned tasks are completed and the problem is resolved, the nurse should make an appropriate entry in the nursing medical record, dated and signed.

The patient’s opinion about the nursing activities carried out is important at this stage. The entire nursing process is assessed when a patient is discharged, transferred to another facility, dies, or undergoes long-term follow-up.

If necessary, the nursing action plan is reviewed, interrupted or changed. When the intended goals are not achieved, the assessment makes it possible to see the factors that hinder their achievement. If the final result of the nursing process leads to failure, then the nursing process is repeated sequentially to find the error and change the plan of nursing interventions. Often the reasons for failure to achieve set goals lie in problems associated with the implementation of the plan. The practical implementation of the plan may be hampered by insufficient supplies of medicines, equipment, and dressings. Successful implementation of the plan of care depends on the nursing staff, their vocational training and competence, from the environment.

The quality of the final assessment, and ultimately the quality of nursing care, depends on how well the other stages of the nursing process are functioning, i.e. each stage provides the basis for the final assessment.

Thus, evaluating the results of nursing interventions enables the nurse to identify strengths and weaknesses in his professional practice.

It may seem that the nursing process and nursing diagnosis are formalism, “extra paper.” But the fact is that behind all this there is a patient who rule of law Effective, high-quality and safe medical care, including nursing, must be guaranteed. The conditions of insurance medicine imply, first of all, high quality medical care, when the degree of responsibility of each participant in this care must be determined: doctor, nurse and patient. Under these conditions, rewards for success and penalties for mistakes are assessed morally, administratively, legally and economically. Therefore, every action of the nurse, every stage of the nursing process is recorded in the nursing medical history - a document that reflects the qualifications of the nurse, the level of her thinking, and therefore the level and quality of the care she provides.

Documenting the nursing process important for a number of reasons:

· helps create valuable baseline patient data and use it with the patient throughout the care process;

· helps to create a dynamic and comprehensive body of information about the patient's needs, goals and objectives of care, planned care, results achieved and their effectiveness;

· it is a means of providing consistency in nursing care;

· is a chronological account of nursing actions and their results that plays important role in certain situations;

· it is material for assessing the effectiveness or ineffectiveness of various types of nursing interventions;

· it is a means of training for medical staff;

· it is the provision of reliable information for medico-legal examination;

· it is a bank of objective data for use in nursing research;

· this is the provision of necessary information to other colleagues helping the patient.

In addition to the above reasons, documentation must adhere to certain principles of record keeping: clarity in

choice of words, brief and unambiguous presentation of information, coverage of all essential information, inadmissibility of using abbreviations (except generally accepted ones), each entry must be accompanied by the date, time and signature of the nurse.

Undoubtedly, and this is evidenced by world experience, 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.

The nursing process has a number of advantages:

– nursing care is planned individually for each patient;

– continuity of care is improved;

– the nursing care plan contains information necessary for all nursing staff involved in care;

– patients prefer to be treated as individuals rather than as a medical diagnosis or patient;

– the nursing process promotes direct participation of the patient and his family in the provision of care;

– nurses are in the process of continuous learning, which helps them improve the quality of care provided;

– it helps nurses understand the reasons for the effectiveness or ineffectiveness of different types of nursing interventions;

– nursing staff receive greater satisfaction from their work (LEMON, 1996)

Topics for tests:

1. Nursing process in medical institutions. Its meaning and necessity. The role of the nurse in organizing and conducting the nursing process.

2. Nursing process in medical institutions. Its meaning and necessity. The role of the ordinary nurse in organizing and conducting the nursing process.

3. Organization of the nursing process in... a department (for example, in a surgical department). The role of the sister leader.

4. Nursing process for... (for example, bronchial asthma). The role of the nurse and the patient in organizing the nursing process.

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

Evaluating the effectiveness of nursing interventions is a multistep process.

It is carried out:

• nurse
• patient
• relatives of the patient
• senior sister of the department
• head of department
• hospital management

Formulation for evaluating the effectiveness of nursing interventions

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

Long term goal: The patient has no PRIORITY PROBLEM by the end of days 10-14 as a result of the combined efforts of the physician, nurse, and patient. The goal has been achieved.

Nursing care Nursing support includes necessary medications. inventory, tools, etc. to achieve your goals.

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Nursing process- a systematic, well-thought-out, targeted plan of action for the nurse, taking into account the needs of the patient. After implementing the plan, it is necessary to evaluate the results.

The standard nursing process model consists of five stages:

1) nursing examination of the patient, determining his state of health;

2) making a nursing diagnosis;

3) planning the actions of the nurse nursing manipulations);

4) implementation (implementation) of the nursing plan;

5) assessing the quality and effectiveness of the nurse’s actions.

Benefits of the nursing process:

1) universality of the method;

2) ensuring systemic and individual approach to provide nursing care;

3) wide application standards of professional activity;

4) ensuring high quality of medical care, high professionalism of nurses, safety and reliability of medical care;

5) in patient care, except medical workers, the patient himself and his family members take part.

Patient examination

The purpose of this method is to collect information about the patient. It is obtained through subjective, objective and additional ways examinations.

A subjective examination consists of interviewing the patient, his relatives, familiarizing himself with his medical documentation(extracts, certificates, outpatient medical records).

To receive complete information When communicating with a patient, the nurse should adhere to the following principles:

1) questions should be prepared in advance, which facilitates communication between the nurse and the patient and allows important details not to be missed;

2) it is necessary to listen carefully to the patient and treat him kindly;

3) the patient should feel the nurse’s interest in his problems, complaints, and experiences;

4) short-term silent observation of the patient before the start of the interview is useful, which allows the patient to collect his thoughts and get used to the environment. At this time, the health care worker can get a general idea of ​​the patient’s condition;

During the interview, the nurse finds out the patient’s complaints, medical history (when it started, with what symptoms, how the patient’s condition changed as the disease progressed, what medications were taken), life history ( past illnesses, features of life, nutrition, availability bad habits, allergic or chronic diseases).

During an objective examination, the patient’s appearance is assessed (facial expression, position in bed or on a chair, etc.), organs and systems are examined, functional indicators are determined (body temperature, blood pressure(BP), heart rate (HR), respiratory rate (RR), height, body weight, vital capacity (VC), etc.).

The legislation of the Russian Federation prohibits abortions outside of a medical institution. If an artificial termination of pregnancy was performed outside a specialized medical institution or by a person with secondary medical education, then on the basis of Part 2 of Art. 116 of the Criminal Code of the Russian Federation, the person who performed the abortion is held criminally liable.

Plan objective examination patient:

1) external inspection(characterize the general condition of the patient, appearance, facial expression, consciousness, position of the patient in bed (active, passive, forced), patient mobility, condition of the skin and mucous membranes (dryness, moisture, color), presence of edema (general, local)) ;

2) measure the patient’s height and weight;

5) measure blood pressure in both arms;

6) in the presence of edema, determine daily diuresis and water balance;

7) record the main symptoms characterizing the condition:

a) organs respiratory system(cough, sputum production, hemoptysis);

b) organs cardiovascular system(pain in the heart area, changes in pulse and blood pressure);

c) organs gastrointestinal tract(state oral cavity, indigestion, examination of vomit, feces);

d) organs of the urinary system (presence renal colic, change in appearance and amount of urine excreted);

8) find out the condition of sites for possible parenteral administration of drugs (elbow, buttocks);

9) determine psychological state patient (adequacy, sociability, openness).

Additional examination methods include laboratory, instrumental, radiological, endoscopic methods and ultrasound. It is mandatory to conduct additional research such as:

1) clinical analysis blood;

2) blood test for syphilis;

3) blood test for glucose;

4) clinical urine analysis;

5) fecal analysis for helminth eggs;

7) fluorography.

The final step of the first stage of the nursing process is to document the information received and obtain a database of patient data, which are recorded in the nursing medical history of the appropriate form. The medical history legally documents independent professional activity nurses within the scope of her competence.

Making a nursing diagnosis

At this stage, physiological, psychological and social problems The patient's problems, both actual and potential, are prioritized and a nursing diagnosis is made.

Plan for studying patient problems:

1) identify the patient’s current (existing) and potential problems;

2) identify factors that caused the emergence of current problems or contributed to the emergence of potential problems;

3) identify the patient’s strengths that will help solve current problems and prevent potential problems.

Since in the vast majority of cases, patients have several pressing health problems, in order to solve them and successfully help the patient, it is necessary to find out the priority of a particular problem. The priority of a problem can be primary, secondary or intermediate.

Primary priority is a problem that requires an emergency or priority solution. Intermediate priority is associated with the patient's health condition, which is not life-threatening, and is not a priority. Secondary priority is given to problems that are not related to a specific disease and do not affect its prognosis.

The next task is to formulate a nursing diagnosis.

The purpose of nursing diagnostics is not to diagnose the disease, but to identify the patient’s body’s reactions to the disease (pain, weakness, cough, hyperthermia, etc.). A nursing diagnosis (as opposed to a medical diagnosis) is constantly changing depending on the patient’s body’s changing response to the disease. At the same time, the same nursing diagnosis can be made for different diseases for different patients.

Planning the nursing process

Drawing up a medical action plan has certain goals, namely:

1) coordinates the work of the nursing team;

2) ensures the sequence of measures to care for the patient;

3) helps maintain communication with other medical services and specialists;

4) helps determine economic costs (as it indicates the materials and equipment needed to perform nursing care activities);

5) legally documents the quality of nursing care;

6) helps to subsequently evaluate the results of the activities carried out.

The goals of nursing activities are the prevention of relapses, complications of the disease, disease prevention, rehabilitation, social adaptation of the patient, etc.

This stage of the nursing process consists of four stages:

1) identifying priorities, determining the order of solving the patient’s problems;

2) development of expected results. The result is the effect that the nurse and the patient want to achieve in joint activities. The expected results are a consequence of the implementation of the following nursing care tasks:

a) solving the patient’s health-related problems;

b) reducing the severity of problems that cannot be eliminated;

c) preventing the development of potential problems;

d) optimizing the patient’s ability to self-help or get help from relatives and close people;

3) development of nursing activities. It specifically determines how the nurse will help the patient achieve the expected results. From all possible activities, those that will help achieve the goal are selected. If there are several types of effective methods, the patient is asked to make his own choice. For each of them, the place, time and method of execution must be determined;

4) entering the plan into documentation and discussing it with other members of the nursing team. Each nursing action plan must have a date of preparation and be certified by the signature of the person who compiled the document.

An important component of nursing activities is the implementation of doctor's orders. It is important that nursing interventions be consistent with therapeutic decisions, be based on scientific principles, be individualized to the individual patient, utilize patient learning opportunities, and allow for active patient participation.

Based on Art. 39 Fundamentals of legislation on the protection of the health of citizens, medical workers must provide first medical care to everyone who needs it in medical institutions and at home, on the street and in public places.

Execution of the nursing plan

Depending on the participation of the doctor, nursing activities are divided into:

1) independent activities - actions of the nurse on his own initiative without the doctor’s instructions (teaching the patient self-examination skills, teaching family members how to care for the patient);

2) dependent activities performed on the basis of written orders from a doctor and under his supervision (performing injections, preparing the patient for various diagnostic examinations). According to modern ideas, a nurse should not carry out doctor’s orders automatically, she should think through her actions, and if necessary (in case of disagreement with a doctor’s prescription) consult a doctor and draw his attention to the inappropriateness of a questionable prescription;

3) interdependent activities involving joint actions of a nurse, doctor and other specialists.

Help provided to the patient may include:

1) temporary, designed for a short time, which occurs when the patient is incapable of self-care, self-care after yourself, for example after operations, injuries;

2) constant, necessary throughout the patient’s life (in case of severe injuries, paralysis, amputation of limbs);

3) rehabilitating. This combination physical therapy, therapeutic massage and breathing exercises.

The implementation of the nursing action plan is carried out in three stages, including:

1) preparation (revision) of nursing activities established during the planning stage; analysis of nursing knowledge, abilities, skills, definition possible complications problems that may arise during nursing procedures; provision of necessary resources; equipment preparation – stage I;

2) implementation of activities - stage II;

3) filling out documentation (complete and accurate recording of completed actions in the appropriate form) – stage III.

Evaluation of results

The purpose of this stage is to assess the quality of the assistance provided, its effectiveness, the results obtained and summing up the results. The quality and effectiveness of nursing care is assessed by the patient, his relatives, the nurse herself who performed nursing activities, and management (senior and chief nurses). The result of this stage is the identification of positive and negative aspects in the professional activities of a nurse, revision and correction of the action plan.

Nursing history

All activities of the nurse in relation to the patient are recorded in the nursing medical history. Currently, this document is not yet used in all medical institutions, but as nursing is reformed in Russia, it is becoming increasingly used.

Nursing history includes the following:

1. Patient information:

1) date and time of hospitalization;

2) department, ward;

4) age, date of birth;

7) place of work;

8) profession;

9) marital status;

10) by whom it was sent;

11) therapeutic diagnosis;

12) presence of allergic reactions.

2. Nursing examination:

1) a more subjective examination:

a) complaints;

b) medical history;

c) life history;

2) objective examination;

3) data additional methods research.

Nursing diagnostics - II stage of the nursing process

The goals of a nursing diagnosis are to analyze the results of the assessment and determine what health problem the patient and family are facing and to outline a plan of nursing care.

After completing the patient's assessment, the nurse proceeds to determinenursing diagnosis. The Greek word for "discernment" for a physician means to determine the cause of suffering based on the identification of symptoms.

Nursing diagnosis - This is a thoughtful conclusion based on the analysis and interpretation of information obtained during the examination, it is discussed on the patient's health-related reactions, rather than on the recognition of diseases.

To understand the meaning and importance of nursing diagnosis, it is necessary to know the evolution of nursing diagnosis.

Discussion of this problem began in the 1930s in the USA. The medical literature on nursing contains many definitions of “nurse diagnosis.” Numerous articles have been published for and against the use of nursing diagnosis. These definitions have changed as the term nurse diagnosis has gained greater understanding among professionals. However, some common components of these definitions include the concept of "nursing", "patient and health problems". In addition, clinical judgment and decision making are implied in each definition.

In the 80s, activity in favor of nursing diagnostics increased, and in 1991. the nursing diagnosis was included in the Standards of Clinical Nursing Practice (USA). What is the difference between a medical diagnosis and a nurse’s diagnosis: (Table No. 4)

Medical (doctor's) diagnosis is a determination of the disease state based on a special assessment of physical signs, symptoms, and medical history. Medical diagnosis focuses on recognizing diseases.

Nursing diagnosis - this is a statement about actual or potential possible reaction patient for a disease (health problem) that the nurse is competent to treat. Nursing diagnosis reflects the patient's level of health or response to illness or pathological process. Doctor's diagnosis anddiagnosis nurses are established on the basis of physiological, psychological, socio-cultural, spiritual and other indicators of the patient’s examination.

Goals and objectives medical diagnosis - determine the disease and prescribe treatment.

Goals of nursing diagnosis - analyze the results of the examination and determine what health problem the patient and his family are facing, as well as outline a nursing care plan.

Nurse diagnostic task - development individual plan care for the patient so that the patient and his family can adapt to changes possible due to health problems.

Establishing a nursing diagnosis - this is the identification of the patient’s health problems.

Nursing diagnoses can be assigned to the patient, family, community, etc. and take into account the physical, intellectual, emotional (psychological), social and spiritual factors identified during the examination.

Structure of nursing diagnosis

Description of the patient's response to the disease

description of the possible reason for this reaction

Table No. 3

Second stage nursing process - nursing diagnosis - involves the following activities:

I . Processing information obtained during the examination

The nurse must be sure that the examination datacorrespond a certain diagnostic measure (standard, reference).

For example, when asking a patient about the nature of the pain, we obtain subjective information. However, palpation of the sore spot and the patient’s face distorted from pain is objective information.

Inattentiveness, haste, and irresponsibility of a nurse can lead to unwanted mistakes. These errors can occur at any stage of the nursing process: during examination and establishment of a nursing diagnosis, drawing up a nursing care plan, practical implementation plan and evaluation of results. American scientists Potter P. and Perry A. recommend some ways to avoid diagnostic errors:

Determine the patient's response to the disease.

Define diagnostic formulation.

Establish a cause that can be cured in the process of caring for the patient.

Determine the patient's need for a particular course of treatment or analysis.

Determine the patient's reaction to the equipment.

Understand the patient's problem, not the nurse's.

Understand the patient's problem, not the intervention.

Understand the patient's problem, not the goal.

Avoid harmful language.

Identify only one patient problem in the diagnostic formulation.

P. Identifying patient problems

After processing the information, the nurse identifies the patient's health problems.

Problems may be:

physical ( physiological )

psychological

social

spiritual

For example: Bcardiological A 70-year-old patient was admitted to the department with severe expiratory shortness of breath and headache, which she developed when she smelled gas. During the examination, the patient was restless, she was worried about the deterioration of her health, and shortness of breath began to occur every time the woman lit the gas stove, and did not go away for a long time. She also told the nurse that she lived alone and there was no one at home to water the flowers; she was worried that they would dry out while she was in the hospital. The woman was also concerned that she was fasting now and whether she would be able to observe it while undergoing treatment.

Table No. 4

We identify the patient's problems.

Physiological - severe shortness of breath, headache.

Psychological - concerns about deteriorating health (attacks have become more frequent), worries about flowers (they will dry out).

Spiritual - fasting.

III. Formulation of nursing diagnoses

Once the patient's problems have been identified, nursing diagnoses must be formulated. The Association of American Nurses (AAM) has identified the main patient problems:

Limiting self-service.

Disturbances in sleep, rest, nutrition, sexuality, blood circulation, etc.

heart failure

nutritional disorder (low, high, etc.)

reduced gas exchange

3. Pain (discomfort)

chronic pain

chronic constipation

diarrhea

4. Emotional instability associated with an illness that threatens health and everyday LIFE.

feeling of fear

feeling of despair, hopelessness

worrying about someone or something

excitement about...

indecision in decision making

lack of desire to take care of oneself

5. Violation mental activity

speech disorder

inadequate assessment of one's condition

situational loss of self-esteem.

Problems associated with life cycles(birth, death, stages of development)

Relationship problems

family conflicts

stressful situations

This is far from full list formulations of nursing diagnoses. The nurse must always remember that her task is not to define a disease, but to determine the level of health status or response to a disease or pathological process.

What nursing diagnoses can be made for the patient in our example?

Severe shortness of breath - impaired respiratory function, decreased gas exchange. Diagnosis:

"Worry about increased episodes of shortness of breath." Diagnosis:

"Worried about flowers left at home." Diagnosis:

"Anxiety about fasting." Diagnosis:

IV. Documentation

All established nursing diagnoses are recorded in the medical history - in the nursing process card. The nurse must clearly know the concept with which she defined the diagnosis so that there is no discrepancy, because the nursing process is carried out by different nurses.

The importance of nurse diagnosis and its application in creating a nursing care plan:

The use of nurse diagnosis is the mechanism by which the nurse's scope of care for the patient is established.

Diagnoses formulated by the nurseprovide direction to the planning process and the choice of treatment modality to achieve the desired results. Expected outcomes are predicted for each nurse diagnosis. The nurse's diagnosis and subsequent treatment plan for patient carehelp communicate patient concerns to other professionals with the help treatment plan care, consultations, discharge plan and conferences on patient care issues.

Nurse diagnosisfacilitates the transfer of information between nurses.

The nurse's initial diagnosis list is an easily accessible reference for determining the patient's current treatment and nursing needs.

Nursing diagnoses alsoencourage the nurse to develop their organizational skills, for they help to give greater importance to the needs of the patient.

Nursing diagnoses are used to compile the nurse's notes on the progress of the patient's condition, to write referrals to a specialist doctor, to carry out effective treatment and care for the patient when transferring him from one department to another, from one hospital to another. When planning the discharge of diagnosed patients, nurses provide a way to convey information and establish what treatment and care the patient still needs.

Nursing diagnoses can servecenter for quality assurance, improvement of nurse performance and joint reviews.

Quality assurance is the control and assessment of the quality and compliance of treatment and patient care in comparison with accepted standards. Improving the quality of a nurse's work is an assessment by professionals of how a nurse carries out her practical work, improves her qualifications, or participates in scientific research.By focusing on the nurse's diagnosis, the reviewer can determine whether the patient's treatment and care was appropriate and carried out in accordance with accepted standards of practice.

The nurse is responsible for his judgment and actions at all stages of the nursing process - from collecting data and assessing the patient's health conditions to assessing effectiveness and achieving set goals.

III stage of the nursing process - planning nursing interventions

Purpose: nursing planning: based on the needs of the patient, highlight priority tasks, develop a strategy for achieving goals, determine the criterion for their implementation.

Nursing assessment and formulation of nursing diagnoses represent a planning step in the nursing process. Planning is a category that defines nursing behavior in defining patient-centered goals and establishingstrategies to achieve goals.During planning:

priorities are set;

goals and expected results are determined;

patient care measures are selected;

possible consequences are established;

a nursing care plan is written.

1. Setting priorities

Once specific nursing diagnoses are established, the nurse determines priorities according to the severity of the diagnosis. Nursing priorities are established to determine the order in which nursing interventions are provided when a patient has multiple problems.

Prioritization is not simply a matter of listing nursing diagnoses according to their severity and psychosocial significance. Rather, it is a method in which the patient and nurse work together to make diagnoses based on the patient's wants, needs, and safety.

Table No. 5

Basic psychosocial needs are one step higher than safety needs. The needs for love, respect and self-expression may be given less attention. The nurse should be aware of situations where there are no emergency physical needs,But priority may be given to the psychological, sociocultural, developmental and spiritual needs of the patient.

Since the patient has several diagnoses, the nurse cannot begin to treat them simultaneously, after they are established. She chooses based on urgency, the nature of the prescribed treatment, and the interaction between diagnoses. Priorities are classified as:

primary

intermediate secondary

Table No. 6

Primary priority (leading importance) is given to the nursing diagnosis (or the patient’s condition, his reaction), implementationwhom requires urgent action, since the patient’s condition and further treatment depend on the solution to this problem.

Let's turn to the nursing process map.

Nursing diagnosis: a feeling of “fullness” in the abdominal area due to long delay stool is given primary priority because, after discussion with the patient, the nurse has

the conclusion is that solving this particular problem is a priority task.

Intermediate Priority is given to diagnoses that do not require emergency measures.

In the case of our patient, these are the diagnoses:

High risk occurrence of repeated constipation associated with poor nutrition and in a sedentary manner life.

Lack of care for your health.

High risk of chronic gastrointestinal diseases as a result of long-term persistent constipation.

Lack of knowledge about rational nutrition.

Secondary priority is the patient's needs that are not directly related to the disease and prognosis.

In our example there are no such ranges, and here the opinions of the patient and the nurse coincide. But the situation may be different. For example, a diagnosis of self-care deficits may be given secondary priority, but this should be a joint decision between the patient and the nurse.

Remember!

1. Care priorities are set to determine the order in which

nursing intervention is carried out.

2. This is not simply a listing of nursing diagnoses according to their severity and
psychosocial significance. This is a method in which the patient and nurse work together to make diagnoses based on the patient's wants, needs, and safety.

2. Defining goals and expected results

Goals and expected outcomes are identified by examining the patient's behavior or response based on the nurse's experience in nursing. After examining, establishing a diagnosis, and determining the patient's primary needs, the nurse formulates goals and expected outcomes for each diagnosis with the patient.

There are two reasons for writing goals and expected results.

First, goals and expected outcomes provide direction for individual nursing care.

Second, goals and outcomes are used to determine the effectiveness of aid.

The purpose of this work is to determine the patient's response to nursing care.

Each goal and each expected result must be allocated time for evaluation. The time allotted depends on the nature of the problem, etiology, general condition of the patient and the treatment prescribed.

Since each patient reacts differently to different life situations Therefore, nursing diagnoses and care goals will be unique (inimitable, individual).

Patient-centered goals require the patient's active participation in defining them, determining expected outcomes, and determining the plan of care.

Goals must be realistic and achievable.

Goals should be specific, not vague, and general formulations should be avoided (“the patient will feel better,” “the patient will not feel discomfort,” “the patient will be adopted”).

The goal should be formulated within the limits of nursing, not medical competence.

Goals must have specific deadlines for their achievement.

The purpose must be clear to the patient, his family, and other health care professionals.

The patient should be maximally involved in the process of planning and implementing programs to protect his health. He has every moral right to obtain the information necessary to make serious decisions, to contribute to the assessment of the advantages and disadvantages of choosing treatment options, to accept, refuse or continue treatment without coercion. Every nurse must be competent in the moral and legal rights of the patient and must protect and support these rights. If the patient is not able to make an independent decision, then it is necessary to find someone who could do this (relatives, guardians). The nurse should also be aware of those situations c. whose individual rights to independence in the field of health care may temporarily fade into the background in order to protect society (for example, if an illness requires isolation of the patient from society or the sick person poses a direct threat to others - sharp forms psychoses, especially dangerous infections, etc.).

Goals should not only meet the immediate needs of the patient, but also include disease prevention and rehabilitation measures.

There are two types of goals allocated for patients: short-term and long-term.

Short term are goals that must be completed in a short period of time, usually less than a week.

Long-term are goals that can be achieved in more long period time, usually over weeks and months (during hospital stay, upon discharge, after discharge). These goals are usually aimed at preventing complications, rehabilitation, and acquiring knowledge about health.

Let's return to the nursing process map.

To solve real problem No. 1 - “a feeling of fullness in the abdomen due to prolonged retention of stool”, two goals have been identified:

short term goal - the patient will empty the intestines on the day of hospitalization with an enema given by the nurse;

long term goal - independent bowel movement by the patient at the time of discharge.

Two other goals:

short-term goal - within a week the patient will receive information about rational nutrition as a result of conversations with a nurse;

long-term goal - by the time of discharge the patient will master exercise therapy complex and self-massage as a result permanent classes with a physical therapy instructor, which allows you to solve everything acute problems patient.

When writing goals, the following mandatory points must be indicated:

Event – action . For example, the patient will empty the intestines on his own
will empty the intestines, receive information, master the complex of exercise therapy and self-massage.

Criterion - number, time, distance. For example, on the day of hospitalization, by the time
discharge, within a week, by the time of discharge.

Condition - assistant, assistant, etc.

For example, with the help of an enema given by a nurse; on one's own; as a result of classes with a physical therapy instructor.

Ultimately, the goal leads to the definition of expected results.

Expected results .

The expected result is a special, stepwise concept that leads to achieving the goal. The result is a change in the patient's behavior in response to nursing care. The results mean changes in the patient’s condition in terms of physiology, sociology, emotional and spiritual state. This change is detected through observation of the patient's reaction.

Planned before the nurse's action planning, O.R. set the direction of nursing activities.

O.R. stem from short- and long-term patient-centered goals and are based on nursing diagnoses. When writing O.R. the nurse must make sure that the result is indicated in proportion to the norms of behavior. They must be compiled sequentially, taking into account time. This will help establish the order of nursing interventions as well as the timing of problem resolution.

Variety of O.R. are determined for each goal and each nursing diagnosis. The reason for emphasizing the variety of expected outcomes is the ability to resolve multiple patient problems with a single nursing action.

(see nursing process map)

O.R. determined when patient-centered goals are achieved. Sister uses O.R. as a criterion for assessing the effectiveness of the sister’s activities.

To avoid common mistakes when writing goals and expected results, you must follow the basic rules:

1. C&R should focus on the patient and his behavior and reactions, rather than on nursing intervention .

It would be correct to define CIR as follows: “the patient will empty the intestines on the day of hospitalization with the help of an enema given by the nurse.”

It is incorrect to define CIR as follows: “to alleviate the patient’s condition with the help of an enema.”

2. C&R must be set in such a way that they can be assessed: observed, measured.

3. C&R must be realistic, since each achieved goal instills in the patient confidence in his get well soon. To do this, the nurse needs to know the health care resources, the family, and the patient.

3. Selection of measures according to nursing

This is the determination of the scope and methods of nursing care (nursing intervention). There are 3 categories of nursing interventions. The choice of category is based on the needs of the patient. One patient may have all three care plan categories, while another patient may only have an independent or interdependent care plan category.

1. Independent intervention. This intervention does not require outside supervision or direction. For example, interventions to increase the patient's knowledge of adequate nutrition or daily activities related to hygiene, massage, relaxation therapy are independent actions of the nurse.

Independent interventions can resolve a patient's problems without consultation or collaboration with physicians or other health care providers. employees. They do not require instructions from a doctor or other specialists.

2. Interdependent intervention. These interventions are carried out by the nurse with another health worker. An example would be the use of hyperintensive treatment, in which the nurse has criteria by which drug and dietary therapy can be modified.

This cooperation can be defined as a partnership in which the value of the two parties is equally valued by both parties, common and separate areas of activity and responsibility are also recognized and accepted, mutual respect for the interests of both parties and also goals that are recognized by both parties.

3. Dependent intervention. These interventions are based on instructions or written instructions. Management of treatment, use of procedures, changing dressings, and preparing the patient for diagnostic tests are dependent nursing interventions.

Prescription various treatments is not within the scope of nursing practice, but the nurse is responsible for carrying out prescribed treatment.

Each dependent intervention requires responsibility and accurate knowledge. When managing treatment, the nurse must know the classification of drugs, their effect, dosage, side effects, nursing interventions related to their effects and side effects.

When applying procedures or changing dressings, the nurse must be sure when the procedures are necessary (indications), have the skills necessary to perform them, and anticipate the expected result and possible side effects.

When ordering a diagnostic test, the nurse must plan its implementation, prepare the patient, and identify nursing applications.

All interventions require the nurse to evaluate and make a decision. When asked to perform a nursing intervention, the nurse should not automatically carry it out, but must determine whether the order is necessary for the patient. Every nurse encounters unnecessary and incorrect assignments from time to time. A nurse with a good knowledge base will recognize the error and find an explanation, because... an error may occur when writing an instruction or when it is reflected in a patient’s card. It is the responsibility of the nurse to clarify the instructions. A nurse who carries out an incorrect or unnecessary order is just as mistaken as the one who wrote it, and is also responsible for the consequences of the error.

Using the example of a nursing process map, we will try to determine what categories of interventions the care plan has.

TO independent factors include:

1. Motor activation of the patient (if professional sister has necessary knowledge);

2. Explanation of the principles of rational nutrition.
TOdependent factors include:

Providing dietary nutrition

Administration of enemas, use of physiotherapy

Introduction of herbal medicines into the diet

Prescription of medications

Nursing care planning involves cognitive and written processes. Individual plan nursing is the result of the knowledge and research of the nurse as well as the knowledge and research acquired from consultants.

A nursing care plan is a written guide for patient care. It reflects the patient's health problems as determined through examination, nursing diagnoses, priorities, goals, and expected outcomes developed through the planning process.

Writing a plan allows you to:

1. Reduce the risk of incorrect care

In hospitals and others medical institutions In the US, a patient often receives care from more than one nurse, doctor, or outside specialist. A written plan of care provides an opportunity to coordinate the plan, conduct consultations, and schedule diagnostic tests.

Allows the other sister to continue care, since the plan's activities can
be performed throughout the day or day after day.

Nurses exchange information.

Nurses create their reports based on the nursing care and treatment provided in the care plan. After sharing information, nurses discuss the patient's care plans with those who will continue to care. This way, all nurses are able to discuss current and already well-researched information about the patient's plan of care.

4. Carry out rehabilitation after discharge.

A written patient care plan also addresses the patient's needs after leaving the hospital. This is especially important for the patient, as he will go through a long course of rehabilitationV society (after surgical interventions, etc.).

The result of complete and accurate nursing care planning is the individualization, coordination and continuation of nursing care. Planning sets the framework for nursing care that must be followed.

IV stage of the nursing process - implementation of the nursing care plan

Do everything necessary to carry out the patient's plan of care (identical to common goal nursing process).

Execution or implementation are activities aimed at:

Help with illness.

Prevention of diseases and complications.

Health promotion.

In theory, implementation of the nursing care plan follows planning, but in practice, implementation may begin immediately after the assessment.

It is sometimes necessary to resort to immediate implementation when there is a threat to the physical, psychological and spiritual state of the patient.

Execution is a category of nursing behavior in which the actions necessary to achieve the expected outcome of nursing care are carried out until completion.

providing assistance

managing activities in daily life

education and counseling of the patient and his family

providing direct assistance in the interests of the patient

assessment of the work of medical staff

recording and sharing information

Table No. 7

After plan care has already been developed and definedIstage of nursing care, the nurse begins to perform, i.e. carries out one or another nursing intervention.

Nursing intervention is any action of the m/s that carries out a nursing care plan or any task.this plan. Nursing care can be dependent, independent, interdependent (see.III step). In addition, nursing interventionscan be entirely based on protocols and guidelines.

Protocol is a written plan that precisely defines the procedures to be performed during the examination.

Note - this is a document containing rules, procedures, regulations for the provision of patient care. Directions have been approved and signed by the attending physician prior to use. They are typically used in intensive care units where patient needs can change quickly and require special attention. The instructions also apply in medical institutions where it is not possible to immediately consult a doctor.

Directives and protocols give the nurse legal protection to intervene in the best interests of the patient. The nurse's responsibility is equal for all types of interventions.

Execution Methods

There are various methods of nursing. To achieve her goals, the nurse makes choices fromthe following methods:

Help with activities related to living needs.

Advice and instructions for the patient and his family.

Nursing care to achieve therapeutic goals.

Nursing care to facilitate the achievement of patient treatment goals.

5. Supervise and evaluate the performance of other staff members.

To achieve the goals of patient care, regardless of the methods used, the m/s must have theoretical knowledge, practical skills and communication skills with the patient and his relatives.

What exactly does each of these methods involve?

1. Assistance in performing activities related to life n y needs.

This is an activity, associated with daily needs, usually carried out during the day and includes eating, dressing, washing, serving the bed, etc.

The patient's need for help can be temporary, permanent or rehabilitative.

In cases of temporary care, such assistance is required for a short time, for example, with a fracture of the upper limbs, the patient will need assistance until the cast is removed.

A patient who is unable to self-care due to damage to the cervical spine will have a constant need for help.

Rehabilitation will help the patient acquire new skills to perform daily needs to become more independent and capable of self-care.

2. Advice and instructions for the patient and his family

Advice is emotional, intellectual and psychological help. Advice, as a method of implementation, helps the patient adapt to new living conditions, cope with problems, stress and facilitates interpersonal relationships between patients, families and staff. Advice is very closely related to teaching. Education (instructions), as a method of implementation, is used to inform patients about their health status and to enable patients to acquire the necessary self-care skills. The nurse is responsible for determining the need for patient education and the quality of instructions given.

3. Patient care to achieve therapeutic goals

To achieve treatment goals, the m/s undertakes interventions to:

a) saving the patient’s life (resuscitation measures, containment of violent
patient, etc.);

b) compensation adverse reactions caused by procedures, medications, diagnostic tests.

For example, the patient previously had an intolerance or allergic reaction to the administration of vitamin preparations. In this case, the m/s must:

stop administering medications;

write down symptoms, if any;

Tell your doctor and administer antihistamines as prescribed.

c) preventive measures.

They are aimed at preventing complications or exacerbations of the disease. For example, preventive measures when identifying allergic reaction:

note in the medical history intolerance to vitamin preparations;

notify the patient and his family;

advise the patient what he should do when re-prescribing these drugs.

4. Patient care to facilitate the achievement of patient treatment goals

These are measures aimed at creating a favorable environment for the patient, i.e. compliance with the medical and protective regime.

The earliest stage of creating the necessary environment will be, for example, when a patient enters the hospital it is necessary to:

escort to the ward;

introduce the staff and other patients;

introduce the daily routine and structure of the department;

provide privacy for performing hygiene needs, etc.;

Encourage and approve the slightest efforts of the patient aimed at recovery.
Nursing and others therapeutic measures designed for the needs of the patient,

Care plans should be flexible, allowing the patient to have choice.

5. Observe and evaluate the performance of other staff members

The nurse developing the plan of care often does not perform all interventions herself. Some of them are entrusted to other employees (junior nurses, nursing assistant, etc.). But the nurse is responsible for the quality of the measures performed.

V stage of the nursing process - assessing the achievement of goals

and expected results

The goal is to determine the extent to which results have been achieved.

Grade is the final stage of the nursing process, which involves three different aspects:

Assessing patient responses to intervention. Patient's opinion about the intervention.

Assessment of achievement of set goals.

Assessing the quality of assistance provided. Impact of the intervention on the patient.

The assessment is performed continuously while the nurse interacts with the patient. The focus is on improving the patient's condition.

What does each aspect of this stage of the nursing process involve?

Assessing patient responses to nursing interventions.

Patient's opinion about the intervention.

While caring for a patient, the nurse compares the results achieved. For example, reducing pain symptoms, improving knowledge about your disease, etc.

The comparison is carried out together with the patient, and the results are based on his opinion.

2. Assessment of achievement of set goals.

Nursing care is needed to help the patient solve his health problems, prevent potential problems and maintain his health. The score shows whether the goal has been achieved.

For example, during the examination the patient feels severe pain in the stomach, holding his stomach with his hands, a grimace of pain on his face. The nurse uses these basic indications to determine a nursing diagnosis, set goals, plan care, and carry out interventions. After nursing actions have been performed, the nurse reassesses the patient's condition by observing the patient's response. For an objective assessmentdegrees Successful in achieving goals, the nurse should do the following:

Check the stated goal to determine the patient's exact wishes regarding his

Behaviors or reactions.

Assess the patient for this behavior or reaction.

Compare target criteria with behavior or response.

Determine the degree of consistency between target criteria and behavior or

Reaction.

Table No. 8

3. Assessing the quality of nursing care.

This aspect of evaluation is to measure the quality of nursing care.

Evaluation criteria are simply the evaluation skills and techniques used to collect data for evaluation. This assessment consists of the patient's opinion or reaction to the quality of care provided and the presence of complications for the intervention.

The assessment is considered positive when the goals and expected results are achieved, negative if the results are undesirable or potential problems have not been avoided. In this case, the nurse must change the care plan and the nursing process is renegotiated. This coordination continues until all problems are resolved.

Let's look at options for achieving goals using the following examples. See Appendix No. 1 and the nursing process map.

After making sure that the expected results and goals have been achieved, the nurse addresses these assessments to the patient, if he agrees, the nurse interrupts this branch of the care plan. If goals are not achieved or are partially achieved, it is necessary to identify factors that impede the achievement of goals and eliminate them.

When hospitalization ends, many patients are discharged before all goals have been achieved and all problems have been resolved.

Importance of the nursing process

The nursing process improves the quality of care;

Maintains communication between medical staff;

Stimulates nurses to improve the level of professional training;

Performs constant monitoring of the patient;

Medical staff treats the patient as an individual;

Thanks to the nursing medical history, it is easier to assess the quality of the nurse’s work and her competence;

The patient, nurse, and environment become participants in the nursing process.

Psychological aspects of communication with the patient

SAMPLE INTERVIEW ALGORITHM

(conversations)

1. Greetings. The key to communication is greeting. In a hospital situation, both basic forms of "Hello" and related forms are acceptable" Good morning!", "Good afternoon!", "Greetings! ", "I'm glad to welcome you! ".

The addressee of the greeting is our patient, so forms of familiarity, casual (“Hello!”) and ceremonial, playful, are excluded. When addressing a patient, the speech form “Hello” must contain the correct tone of communication; signs of goodwill serve as a base (key) and necessary contact.

Introduce yourself: “My name is...”.

Find out if the patient is willing to talk with you. To this end, you can ask the following questions: “Will you allow me to talk to you?” or “Can I ask you a few questions?”

4 . Ask the patient to introduce himself; familiarity is unacceptable in communication (addressing as “you”, by name, etc.). This may be considered offensive by the patient. Addressing “you” indicates great politeness. The delicately egalitarian form of addressing “You” and by first name and patronymic is justified.

Ask about his complaints, when the disturbances appeared, when the patient first noticed them. “How are you feeling?”, “What’s bothering you?”, or “What are you complaining about?”

Developing an adequate self-assessment by the patient of his worries and concerns. Find out what the significance of this symptom is, how the patient reacts to his complaints; and try to interpret his condition positively. The patient will feel relieved if the nurse allays his fears.

For example. The patient recently developed angina. The patient shows anxiety about the course of the disease. In this case, you can tell him about the facts of the risk and, depending on the specific circumstances, say: “You don’t smoke, you don’t have diabetes, your blood pressure is normal now, all these are favorable factors. You got sick recently, which means the disease has not yet advanced ".

SUCH CONVERSATIONS DO NOT JUST CALM THE PATIENT, THEY SHOW HIM A FAVORABLE PERSPECTIVE AND MOVE HIM INTO AN OPTIMISTIC WAY.

Treatment to date and its results.

Probable causes of the disease.

Time of onset of the first symptom.

Past illnesses (surgeries, injuries, allergies, wounds).

Risk factors, habits (coffee, smoking, alcohol, drugs).

Illness of family members, family history (risk factors in terms of cancer diseases, cardiovascular diseases, diabetes, kidney disease, hypertension, mental disorders).

Working conditions, occupational hazards, habitat (unfavorable environmental conditions).

Psychological climate (social circle, temperament, character, level of development in general, lifestyle, beliefs, moral values).

Social status (role in the family, at work, financial situation).

The impact of the patient's disease and problems on him and his environment. (Does he feel anxiety or internal tension due to this):

a) for professional activities;

b) for family or partner;

c) on interpersonal relationships, on contacts;

d) for future prospects.

Appendix No. 1

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

Use the most reliable source of information - if not the patient himself, then his immediate family.

Use what you have previously learned about the patient's diagnoses (if you know them) to plan in advance what information to focus on and get the facts we need.

Before you begin, explain that the more you know about the patient and his family, the more best care You can provide for him, that's why you ask him a lot of questions.

Take short notes during the interview. Carefully record the dates, number and duration of hospitalization and onset of illness.

DO NOT RELY ON YOUR MEMORY!

Don't try to write in complete sentence form.

Be calm, unhurried, and empathetic. Show genuine interest and empathy.(Sensitivity encourages the patient and facilitates the expression of his feelings).

Do not become annoyed or irritated if the patient experiences memory loss. If you treat this with understanding, he may remember the necessary information later when answering the relevant question.

Use proper eye contact. Carefully observe the patient's body language.

Do not stare at the patient or your notes for too long.

Use neutral questions that encourage the patient to articulate his feelings and provide additional information.

Use leading questions sparingly to focus on unclear points. Use the patient's appropriate words to clarify information. Saying" cutting pain"Do you mean sudden, severe pain?"

Use patient-friendlyterminology . If you doubt that he understands you, ask him what he means by this or that concept.

14. To make the patient feel the appropriateness of interviewing, first of all, ask about his complaints.DON'T START WITH PERSONAL QUESTIONS!

Allow the patient to finish the sentence, even if he is too verbose. Only then ask questions. Don't jump from topic to topic. Don't repeat the question unnecessarily. If a question needs to be repeated, rephrase it for better understanding.

Be understanding of what the patient says. A simple nod, assent, or approving look will help him continue the story, especially if the patient is not dominant.

Call the patient by name. Be friendly, helpful and caring.

Don't lose your professionalism. Speak clearly, slowly and distinctly.

KNOW LISTEN !

In general, it has been observed that a balanced personWith With a sense of self-esteem he comes closer to his interlocutor, while restless, nervous people try to stay away, especially from the interlocutor of the opposite sex. When it is not known in what position the patient feels most comfortable, then you need to observe how he enters the office, the ward, how he sits, stands, holds the chair, how he moves when he thinks that they are looking at him. It is important to pay attention to the relative position and posture of the nurse and the patient.

II . Poses - reflect the state of a person and the relationship to what is happening. Almost every person has their own favorite pose orposes, therefore, it is not always easy to understand whether a given pose is an expression of a person’s state in at the moment or is it just a tribute to habit. On the other hand, a frequent preference for one position or another may express a person’s susceptibility to the corresponding state. At the same time, if a person often takes the same position, as if out of habit, it is possible that he is most often thoughtful, uncommunicative, etc.

Poses can be open or closed. An open pose is determined by: turning the body and head towards the interlocutor, open palms, uncrossed position of the legs, relaxed muscles, “direct” gaze into the face.

Closed posture: Crossed legs or arms usually reflect defensive reaction and reluctance to communicate.

A quick sharp tilt or turn of the head, or gestures indicate that the patient wants to speak.

Sh. Movement and gestures.

Movement is understood as the movement of the entire body in space, and gestures are movements of various parts of the body, but the movements of the head, shoulders and arms are of primary importance.

Communicative gestures (gestures that have independent meaning and do not need verbal explanations - a nod of the head in agreement, a raised finger) are made, as a rule, specifically (consciously) to convey the necessary information to the interlocutor. These are gestures: greetings, farewells, questioning, affirmative, threatening, denying, etc.

Expressive gestures and movements are often involuntary. From them you can “read” a person’s state, his attitude to what is happening. And also determine the assessment of people, events, etc., which perhaps he would like to hide. Gestures: ignorance, distrust, confusion, surprise, irony, displeasure, suffering, approval, joy, delight.

Communicative and expressive gestures may not coincide with speech and even contradict it. In this case, two options are possible:

A person deliberately wants to express with a gesture something completely different from what he forms in
speech (subtext).

A person does not say what he feels, and gestures give away, but to better understand the patient, one must be able to “read” them.

Active gestures often reflect positive emotions and are perceived as a sign of interest and friendliness. Excessive gesturing, however, can be an expression of anxiety and insecurity. Most gestures are multi-variant. For example, waving your hand can be used as a sign of desperation, attracting attention, or giving up something. Nodding your head does not always mean agreement - often they only show the speaker that he is being listened to and is ready to listen further. They seem to give permission to the speaker to continue speaking.

IV . Facial expressions. Eco coordination of facial muscle movements, reflecting states, feelings, emotions. “Facial expressions are visual language,” the main means of verbal communication, it is a signal about a person’s intentions and emotions. There are facial expressions of the upper and lower parts of the face. It has been noticed that the upper part of the face is controlled by us more than the lower part. Therefore, if you want to learn more about a person, his condition, motives and even thoughts, look more often at the horn, the wings of the nose, and the chin. Human lips are especially expressive. Tightly compressed lips express deep thoughtfulness, curved lips indicate doubt or sarcasm. Corners of the mouth - indicators vitality personality. The corners of the mouth downward are a symptom of depression, depressive state, in a joyful, cheerful state, the corners of the mouth align. The frontalis muscle is a muscle of attention or alertness; it is activated when there is danger or aggressiveness.

Fear: The eyebrows are almost straight and seem slightly raised, the eyes are widened, the lower eyelid is tense, and the upper one is slightly raised.PoWhen in fear, it is open and has a narrow elliptical shape, the lips are tense and slightly stretched. How fear is stronger, the more the corners of the mouth are pulled back.

Eyes. Eye contact.

People are sociable, open, focused on others (extroverts), look at the interlocutor more closely and longer than introverts, closed people, focused on themselves. A glance expresses our interest and helps us focus on what we are being told. If the speaker either looks into the eyes or looks away, this means that he has not finished speaking yet. If he looks straight into the eyes at the end of the phrase, he reports that he has said everything. The gaze should not be too intent (directly into the pupils). Staring can be perceived as a sign of hostility, so in argumentative situations people avoid eye contact so that the contact is not understood as an expression of hostility.

• Economy and geography of the state
• Social trends in society
• Attitude of medical workers to their duties
• Attitude medical personnel to social conditions and society as a whole
• State of health care system in the state
• The attitude of the person directly giving the definition to the medical field, as well as much more

Definitions of nursing that can be given by:

• doctors
• nurses
• patients and their loved ones
• education workers
• social workers
• insurance agents will be very different

All-Russian scientific and practical conference, held in 1992. in Galitsino, “According to the theories of nursing” gave approximately the following definition of this science:

Nursing - part medical care for health, aimed at addressing current and potential health problems in a changing environment.

In the 60s Committee of Experts Nursing has been defined as “the practice of human relationships” and the nurse “must be able to notice the needs of the person (as an individual human being) caused by illness.

In 1961 Virginia Henderson- an American nurse and teacher - the most established and canonical definition was given, which reads:

Nursing is assistance in providing a sick or healthy person with those actions that are related to his health, recovery or peaceful death, which the patient would take himself if he had the necessary strength, skills and knowledge, and will.

Moreover, this is done in such a way that the patient gains complete independence as soon as possible.

In 1984, American nurses defined:

A nurse is a person, which nourishes, cherishes, protects; and is always ready to help the weak.

However, Florence Nightingale was the first to give such a definition (“Notes on Care” - 1859), saying that:

Nursing is action on using the patient’s environment for his own recovery. At the same time, it turns out that the nurse does not treat, but creates the most optimal conditions for natural recovery.

Florence sincerely believed that the most important tasks nurses is:

• patient care (creating conditions under which the disease does not occur);
• care healthy person(help in experiencing satisfaction from life even at the time of illness).

She was the first to argue that the skills of a doctor and a nurse are completely different things, affecting different layers of theoretical and practical knowledge.

Differences between the medical and nursing professions

All efforts made by doctors (regardless of the type of activity and approaches) are aimed at studying, describing and combating the disease. At the same time, the same principles apply both in medical and research (scientific) practice. But every disease poses other questions to the patient that need to be addressed.

For example, a doctor who has overcome an illness in the form of a spinal injury does not take into account the possible consequences in the form of decreased motor activity, decreased muscle tone, etc., but such problems for the patient are no less important than getting rid of the illness itself. And this is where the nurse comes to the rescue.

It is she who must teach the patient how to adapt to new conditions associated with suffering a serious illness. She helps the patient organize optimal methods of self-care, find his place in society, and teaches the basics of self-hygiene and prevention.

Means, Nursing is first and foremost person centered(personality, part of society, social unit) and not on the disease. In this case, the main task becomes solving problems associated with changes in the normal rhythm of life.

It follows that nursing has enormous potential and can independently be considered on a par with medical discipline. This means that the responsibilities of a nurse are much broader than simply carrying out doctor’s orders. She is responsible for:

• patient care
• providing necessary assistance
• maintaining health
• disease prevention
• rehabilitation
• relief of suffering
• patient education and consultation

As a leader, the nurse must have the makings of a leader, manager, psychologist and teacher. However, its activities are not limited to:

• social
• political
• religious
• state
• racial
• age
• sexual
• personal
• any other framework, but spreads everywhere and everywhere

International Council of Sisters(1987) gave another definition of nursing:

Nursing is component health systems, aimed at promoting health, preventing morbidity, providing psychosocial assistance and care to people suffering from diseases and disabilities of all types.

This assistance is provided both within the medical institution and outside its walls: at home, in the field, wherever there is a need.