The purpose of the final assessment is to determine the outcome of nursing care. Evaluation is carried out continuously until the patient is discharged.
The nurse collects, analyzes information, draws conclusions about the patient's response to care, about the possibility of implementing a care plan, about new problems.
If all goals are achieved and the problem is solved, the nurse notes this in the plan for achieving the goal for this problem, puts the date, signature.
2.3 Conclusions
After analyzing the cases of glomerulonephritis, we can conclude: knowledge of the etiology, clinical picture, diagnostic features, methods of examination and treatment of the disease, prevention of complications, as well as knowledge of manipulations will help the nurse to carry out all stages of the nursing process.
The nurse must know all the rules for caring for patients, skillfully and correctly carry out the doctor's prescriptions, clearly and clearly present the effect of medicines on the patient's body. The treatment of angina pectoris largely depends on careful and proper care, adherence to the regimen and diet.
4. Conclusion
Having studied in depth the "Nursing process in glomerulonephritis", analyzing two cases from practice, it was concluded that the goal of the work was achieved. In the course of the work it is shown that the use of all stages of the nursing process, namely:
Stage 1: assessment of the condition (examination) of the patient;
Stage 2: interpretation of the data obtained (identification of the patient's problems);
Stage 3: planning the upcoming work;
Stage 4: implementation of the drawn up plan (nursing interventions);
Stage 5: evaluation of the results of the listed stages
Improves the quality of nursing care.
The knowledge and skills gained in the course of writing the term paper are the necessary conditions for the provision of nursing care, having written this term paper, I learned better about the disease glomerulonephritis and learned to apply my knowledge in practice.
5. Literature
K.E. Davlitsarova, S.N. Mironova - Manipulation technique; M .: - Forum infra 2005. – 480 s.
V. G. Lychev, V. K. Karmanov - Guidelines for conducting practical classes on the subject "Nursing in therapy with a course of primary medical care": - educational methodological guide M .: - Forum infra, 2010. - 384 p.
V. G. Lychev, V. K. Karmanov - Fundamentals of nursing in therapy - Rostov n / D Phoenix 2006 - 512 p.
IN AND. Makolkin, S.I. Ovcharenko, N.N. Semenkov - Nursing in therapy - M .: - LLC Medical Information Agency, 2008. – 544 p.
S.A. Mukhina, I.I. Tarnovskaya - Theoretical Foundations of Nursing - 2nd ed., Rev. and add. - M .: - GEOTAR - Media, 2010. - 368 p.
S.A. Mukhina, I.I. Tarnovskaya - A practical guide to the subject "Fundamentals of Nursing"; 2nd edition Spanish. add. M.: - GEOTAR - Media 2009. - 512 p.
T.P. Obukhovets, T.A. Sklyarov, O.V. Chernova - Fundamentals of nursing - ed. 13th add. revised Rostov n / a Phoenix - 2009 - 552s
Final Fifth Step of the Nursing Process- assessment of the effectiveness of care and its correction if necessary. Stage goals:
- assess the patient's response to nursing care;
- evaluate the results and summarize;
- draw up a discharge epicrisis;
- analyze the quality of the assistance provided.
Assessment of care is carried out not only on the day the patient is discharged from the hospital, but constantly, at each meeting: on a round with a doctor, during procedures, in the corridor, in the dining room, etc. The patient's condition changes daily and even several times a day, which is not always caused by the nature of the disease and treatment. This may be due to relationships with roommates, medical staff, attitudes towards procedures, news from home or from relatives. Monitoring the patient is also an action of the nursing staff. It is necessary to notice the slightest changes in the condition or behavior of patients, considering behavior as one of the main evaluation criteria. With each contact with the patient, the nursing process begins anew. For example, a patient after surgery in the morning could not change the position of the body on his own, and after 3 hours the nurse noticed that he was turning over without assistance. This is both new information about the patient and an evaluation criterion. Changes in the behavior and condition of the patient, reflecting a positive trend - another victory for the medical staff. Unfortunately, sometimes treatment and care is ineffective. For example, a patient, after completing the planned measures to reduce the temperature, after a drip infusion, again complains of chills.
Not always and not all problems, evaluative characteristics are recorded, more often (if they do not affect the course of the disease or prognosis) they are simply stated by the nursing staff and verbally transmitted by shift. Conversely, the evaluation and recording of the patient's condition in the intensive care unit is carried out in our clinics every half an hour or an hour. If the patient requires increased attention from the staff, the criteria for assessing his condition are entered in the duty book, discussed at the beginning of the working day at the “five minutes” and in the evening when the shift is handed over.
For the qualitative conduct of the final stage of the nursing process, it is necessary: to know which aspect you want to evaluate; have sources of information important for the assessment; clarify the evaluation criteria - the expected results that the nursing staff wants to achieve together with the patient.
Rice. Step Five of the Nursing Process
Assessment aspects
Assessment stage is a mental activity. Based on the use of certain evaluation criteria, nursing staff will have to compare the existing results of care with the desired ones: evaluate the patient's response and, on this basis, draw a conclusion about the results obtained and the quality of care. For an objective assessment of the degree of success of care, it is necessary:
- clarify the goal and the expected result in the behavior or response of the patient to the disease or his condition;
- assess whether the patient has the desired response or behavior;
- compare the evaluation criteria with the existing reaction or behavior;
- determine the degree of consistency between goals and the patient's response.
Criteria for evaluation
Evaluation criteria can be the words or behavior of the patient, data from an objective study, information received from roommates or relatives. For example, in case of edema, the assessment criteria can be weight and water balance indicators, in identifying the level of pain - pulse, position in bed, behavior, verbal and non-verbal information and digital scales for assessing pain (if used) (Table 15-1).
If the goals are met, the patient's problem is solved, the nursing staff should make an appropriate entry in the medical history, put the date of the solution of the problem and their signature.
Sometimes the patient's opinion about the actions taken plays a decisive role at the assessment stage.
Estimation sources
The source of evaluation is not only the patient. Nursing staff takes into account the opinion of relatives, roommates, all members of the team involved in the treatment and care of the patient.
Evaluation of the effectiveness of all care is carried out when the patient is discharged, transferred to another medical facility or to the pathoanatomical department in case of death.
If necessary, the nursing action plan is revised or interrupted. When the goal is partially or completely not achieved, the reasons for the failure should be analyzed, among which may be:
- lack of psychological contact between the staff and the patient;
- language problems in communication with the patient and relatives;
- incomplete or inaccurate information collected at the time of admission of the patient to the hospital or later;
- erroneous interpretation of problems;
- unrealistic goals;
- wrong ways to achieve goals, lack of sufficient experience and professionalism in the implementation of specific care activities;
- insufficient or excessive participation of the patient and relatives in the process of care;
- unwillingness to ask colleagues for help if necessary.
Actions of nursing staff in the absence of the effect of care
If there is no effect, the nursing process starts all over again in the same sequence.
Evaluation allows staff not only to find out the patient's response to the care provided, but also to identify the strengths and weaknesses of their professional activities.
Drafting a discharge summary
By the end of a patient's time in hospital, short-term care goals have often already been achieved. In preparation for discharge, a discharge summary is drawn up, the patient is transferred under the supervision of a district nurse, who will continue care to achieve long-term goals related to rehabilitation and relapse prevention. The epicrisis provides for a reflection of all the care received by the patient in the health facility. It fixes:
- problems present in the patient on the day of admission;
- problems that appeared during the stay in the department;
- the patient's response to the care provided;
- problems remaining at discharge;
- the patient's opinion about the quality of care provided. Nursing staff who continue to care for the patient after discharge have the right to reconsider the planned activities in order to quickly adapt the patient to home conditions.
A sample of filling out an epicrisis is presented in the NIB at the end of the chapter. Rules for issuing a discharge summary in the nursing care card for the patient Korikova E.V. are given in the NIB at the end of the section.
Table. Examples of problems and criteria for assessing the achievement of the goal
Table. Comparison of purpose and patient response to care provided
Table. An example of a nurse's actions if the goal of care is not achieved
Is there a future for the nursing process?
The problems that a medical worker solves while caring for patients are themselves fraught with tension, anguish and worries. If we add to this the mistakes, blunders, human weaknesses, trials that everyday life exposes, then the congestion of medical workers, their intense rhythm of life, sometimes not maintaining the load, will become clear. This can be avoided by a good organization of work, which is largely due to the introduction of modern nursing technology - the nursing process.
Many people think that the nursing process is a formalism, “extra paperwork” that there is no time to fill out. But the fact is that behind this is the patient, who in a state of law should be guaranteed effective, high-quality and safe medical care, including nursing.
A nurse is an equal member of the medical team, necessary for both a great surgeon and a brilliant therapist. In a number of healthcare facilities that are trying to improve nursing technologies, both understanding and support from doctors are noted, and without this, innovations are impossible.
In institutions of practical health care, "Patient Nursing Care Cards" began to be maintained. These examples show that they do not start it for everyone, more often for a geriatric, doomed, difficult patient. In practice, it is compact, designed for a professional and not so voluminous compared to the example that you saw in this tutorial. The form of maintaining such a document is arbitrary: a map and cannot be standard. Its value lies in reflecting the work of this team of nurses, taking into account its features and the specifics of patients. Recording each action of a sister in caring for a particular patient in the nursing observation card makes it possible to determine the volume and quality of care provided, compare the care provided with the standards, blame or justify the sister if necessary. The absence of such a document, showing the participation of nursing staff in the process of managing a particular patient, in practical healthcare nullifies his responsibility for his actions.
Representatives of healthcare facilities that have introduced an experimental "Nursing Patient Care Card" say that this is a chance to improve the quality of nursing care, evaluate participation and show "one's face" in the treatment process, and solve a number of problems (primarily in favor of the sister and the patient).
Health is a lot of work. Illness is always a big and difficult "adventure". To follow its development, to thoroughly study the problems of the patient, to be happy to solve complex problems in the course of treatment are the most important goals of the work of a nurse.
The introduction of new nursing technologies into the practice of medical institutions, providing for a creative approach, can ensure the further growth and development of nursing as a science, have an effective impact on the quality of medical care, and raise the significance and prestige of the profession in the healthcare system.
findings
- The fifth and final stage of the nursing process is the assessment of the effectiveness of care and its correction if necessary.
- The source of evaluation is not only the patient, the nursing staff takes into account the opinion of relatives, roommates, all members of the team involved in the treatment and care of the patient.
- The words or behavior of the patient, data from an objective study, information received from roommates or relatives can be used as evaluation criteria. The behavior of the patient is one of the main criteria for evaluating care.
- Evaluation allows nursing staff not only to assess the patient's response to the care provided, but also to identify the strengths and weaknesses of their professional activities.
- Evaluation of the effectiveness of all care is carried out by nursing staff when a patient is discharged, transferred to another health facility, or a pathology department in case of death. Information obtained at the time of the final assessment should be analyzed and recorded in the discharge summary of the nursing history. Here, not only the volume of nursing care provided and the patient's response to care are noted, but also problems that need to be addressed after the patient is discharged from the hospital.
- Nursing staff continuing post-discharge care have the right to re-evaluate planned activities to help the patient adapt to home conditions as soon as possible.
- Maintaining a "Patient Nursing Care Card" in practical healthcare is a chance to improve the quality of nursing care and evaluate the role of nursing staff in treating patients.
Fundamentals of nursing: a textbook. - M. : GEOTAR-Media, 2008. Ostrovskaya I.V., Shirokova N.V.
At this stage, the result of care, the achievement of the goal, is evaluated. At the same time, not only the preliminary activities are analyzed, including the definition of criteria and the multiplicity of the result assessment, but also the activities for the implementation of the care plan:. determination of the patient's condition at the current moment;
. assessment of the achievement of goals;
. identification of aspects influencing the achievement of goals;
. modification of the nursing diagnosis, goal and/or plan of care, if necessary.
Both the staff and the patient need to be involved in the evaluation of nursing care at this level.
For the qualitative conduct of the final stage of the nursing process, you need to know which aspect is supposed to be evaluated; have sources of information (patient, medical staff, relatives) necessary for the assessment; clarify the evaluation criteria - the intended result that the nursing staff strives to achieve together with the patient.
Assessment aspects:
. patient responses to nursing care;
. obtaining results and summing up;
. registration of the discharge epicrisis;
. the quality of the assistance provided.
The words or behavior of the patient, data from an objective study, information received from roommates or relatives can be used as evaluation criteria. For example, in case of edema, weight and water balance indicators can act as evaluation criteria, in identifying the level of pain, pulse, position in bed, behavior, verbal and non-verbal information and digital pain assessment scales (if used).
If necessary, the nursing action plan is revised or interrupted. When the goal is partially or completely not achieved, the reasons for the failure should be analyzed, among which may be:
. lack of psychological contact between the staff and the patient;
. language problems in communication with the patient and relatives;
. incomplete or inaccurate information collected at the time of admission of the patient to the hospital or during the stay in it;
. erroneous interpretation of problems;
. unrealistic goals;
. wrong ways to achieve goals, lack of sufficient experience and professionalism in performing specific care activities;
. insufficient or excessive participation of the patient and relatives in the process of care;
. unwillingness to seek help from colleagues if necessary.
When preparing the patient for discharge, a discharge summary is drawn up. It provides for a reflection of all the care received by the patient during the stay in the health facility. Here are fixed:
. problems present in the patient on the day of admission;
. problems that have joined during the stay in the department;
. the patient's response to the care provided;
. problems with which the patient is discharged;
. the patient's own opinion about the quality of care provided. Nursing staff who will continue to care for the patient after discharge have the right to review the planned activities in order to quickly adapt the patient to home conditions.
Evaluation of the success of nursing care is carried out in accordance with the goals. This may be an assessment of the degree of independence of the patient, the ability of relatives to communicate effectively with him. Achieving the goal of effective communication means that the nursing staff and family members of the patient understand both verbal and non-verbal information, correctly respond to various requests from him and can anticipate them.
8.10. NEED FOR WORK AND REST
It is well known that a person spends one third of his life in a dream, most of it - in work and the rest of the time - on vacation. Work and rest are complementary concepts that are equally important aspects of life. The term "work" in the generally accepted sense means the main activity of a person during the day for the sake of earning money, which makes it possible to provide a certain standard of living. Since work is a vital necessity, it is often spoken of with a negative connotation, although it often determines the meaning and sometimes the purpose of life, allows you to communicate with people, and increases family and social status.
Working from home (not to be confused with housework) has both its advantages (savings in transport costs, less wear and tear of clothes and shoes, no strict schedule) and disadvantages (no communication).
Even when people work for money, money is not the only argument for which a person works. So, most of the nursing staff, receiving a small salary, work because of the need to help people, journalists need to self-realize through publications in the media, i.e. people, choosing this or that profession, see in it not only a source of income. It is important to remember that a woman who raises children and does not receive wages for this also works.
Any work (paid or free) is a meaningful useful pastime. Recreation is what a person does during non-working hours: games, sports, music, travel, walks, etc. The purpose of recreation is to have fun. Often the concepts of "work" and "leisure" are intertwined. For most people, sport is recreation, and for athletes it is work. There are many examples where work for some is rest for others and vice versa.
As a rule, a person achieves success in the profession in his mature years (40-50 years), while for athletes this peak occurs at 20-30 years, for politicians, leaders it occurs more often after 50 years. During these periods, a person has the maximum opportunities for relaxation. In old age, it is better to do the usual work and provide yourself with the usual kind of rest.
The goals that an adult sets for himself when choosing one or another type of recreation are different: some consider being outdoors a recreation, others consider maintaining physical fitness, others consider thrills (mountaineering, slalom, etc.), others consider communication, fifth - aesthetic development and education (literature, museums, theater, music, etc.). The main purpose of recreation is to have fun and prevent boredom.
Theoretically, a person who retires has more time to relax. However, given the small size of pensions, people very often work as long as they have the strength and opportunity. When people stop working, many people have certain problems:
Loss (change) of social status and role in society, family;
Loss of the ability to communicate;
Loss of earnings;
Loss of the meaning of life.
Thus, the dynamics of work and leisure change at different stages of life: the beginning of school - the end of school - the beginning of work - a change of job - promotion - retirement.
It should be remembered that work in adulthood and rest in childhood are important components in life and the imbalance of them is harmful to health. Work brings a person money, which often gives him independence. Often, the independence of people of mature age is precisely of a financial nature, which allows them to choose one or another type of recreation, although this choice does not always contribute to health promotion.
Naturally, weakness and deterioration in health in old age increase dependence on other people or devices (canes, glasses, hearing aids, etc.) both during work and during leisure, although some people of retirement age consider themselves more independent, than before.
People suffering from physical disabilities (congenital diseases or injuries), unable to learn, with mental illness or impaired function of the sense organs are dependent on the choice of work and type of recreation throughout their lives. The choice of this or that type of activity is influenced by many factors, primarily physical data and health. For example, the profession of a nurse requires the applicant to be in good physical shape and health, although in some departments of medical facilities, nursing work is quite monotonous and sedentary.
Diseases that lead to the deterioration of physical health (obesity, diseases of the respiratory system, blood vessels and heart, musculoskeletal system, diabetes mellitus) often do not allow a person to engage in a certain type of activity and recreation.
Psychological factors also influence the choice of the type of work and rest. Game forms of education in childhood and productive work of adults contribute to the intellectual, emotional and general development of the personality, which is an important factor that allows a person to choose a profession. Temperament and character (patience, irritability, sociability, desire for solitude, self-discipline) influence the choice of work and rest. Thus, indiscipline leads to the creation of hazardous situations in the workplace that pose a threat to health. A nurse who does not follow safety precautions when working with electrical equipment, the correct biomechanics of the body when moving a patient or lifting heavy objects, universal precautions when working with body fluids or infected care items, endangers only herself, but also patients, colleagues and others. people, including family members.
In the slogan "Observe safety in the workplace" many people invest primarily in the concept of physical safety, but you should also think about reducing the real and potential risk of emotional stress. In nursing, as in many medical professions, emotional stress is an occupational risk, since most people working in the healthcare system often see pain, death and empathize with those who suffer. They are next to patients who are depressed, doomed, often present at the death of a patient. Diseases such as diabetes mellitus, coronary heart disease, peptic ulcers, headache and depression are often associated with stress.
Lack of work has equally important psychological consequences, both for the person himself and for his family. People who have lost their jobs are more likely to suffer from insomnia, depression, anger, their worthlessness. The unemployed are more likely to commit suicide, they are more likely to have somatic and mental illnesses. The fear of being fired creates serious psychological problems for a person (especially for a man). For some, being fired from a job is tantamount to an early death.
Nursing staff, conducting an initial (current) assessment of the patient's condition, should take into account the impact of work on health. It is necessary to clarify the conditions in which a person works:
Is safety ensured at the workplace (safety glasses, gloves, clothing), do others smoke;
Is the noise level controlled (increased noise level leads to stress, irritability, fatigue, decreased attention, injuries, high blood pressure, stroke. At a noise level of 90 dB or more, a person must be provided with headphones);
Is the temperature at a comfortable level, etc.
The literature describes the so-called sick building syndrome, a long stay in which, due to exposure to noise, heat, cold, high humidity, electromagnetic radiation, causes people headache, fatigue, decreased attention, tearing, runny nose, sore throat.
The impact of adverse environmental conditions on women and men of reproductive age leads to serious consequences. Women experience infertility, spontaneous abortions, stillbirth, the birth of children with birth defects, and oncological diseases. Men can develop infertility, impotence, and their children can develop cancer.
Initial assessment
Data on satisfaction of the need for work and rest can be obtained by a nurse during a nursing assessment, using her erudition and knowledge. You should find out:
What type of activity the patient is engaged in, what type of rest he prefers;
The length of the working day and rest;
Where does the person work and by whom;
What factors affect a person at work and leisure;
What does a person know about the impact on health of the conditions of his work and rest;
How does a person relate to his work and leisure;
Are there problems at work and during leisure time and how does he cope with them;
What problems with work and leisure exist at the moment and what problems may arise.
Answers to these questions can be obtained at the same time when conducting an initial assessment of the satisfaction of the patient's needs for movement, maintaining a safe environment, since all these needs are closely related.
Patient problems
Solving problems that have arisen in connection with the dissatisfaction of the need for work may be beyond the competence of nursing staff. In this case, the nurse involves competent specialists in solving this problem or gives advice on where to go for help.
It should be remembered that a new job, dismissal, retirement play an important role in a person's life. People with such problems will be happy to accept psychological and emotional support from anyone, especially from a nurse.
All problems that arise within this need should be grouped as follows:
Changes in the state of independence;
Changes in work and leisure associated with the use of drugs and alcohol, with unemployment;
Changes in environment and habitual activities due to stay in a medical institution.
Independence in activities related to work and leisure is highly desirable for any adult. Those who cannot keep it feel disadvantaged, because they become dependent on the family or the state.
Causes forcing addiction are associated with physical or mental illness, impaired function of the sense organs. Physical diseases, depending on the nature and degree of damage to organs and systems, lead to the fact that the performance of the usual work is often unrealistic, and only passive rest is possible. This is especially true for patients with diseases and injuries leading to disability due to impaired mobility.
The degree of dependence of patients is different, they require different adaptation to new working conditions and types of recreation. For example, people who worked outdoors before the disease, athletes experience significant difficulties in adapting to the conditions of sedentary work and passive rest. At the same time, people who were previously engaged in sedentary work are easier to adapt to new conditions of work and rest. Sports competitions for the disabled, including even the Paralympic Games, allow people accustomed to an active lifestyle to realize their need for one form or another of recreation.
Loss (decrease) of the function of the sense organs often leads to difficulties in communication, which also affects the choice of work and type of leisure. Reduced vision (blindness) creates problems associated with the need to change jobs. Special courses provide an opportunity to master the skills of reading literature published using a special Braille font. Radio, telephone, tape recorder, computer (blind typing) and mastering new professions allow these people to some extent maintain independence both at work and at leisure.
With hearing loss, even at the very beginning, a person learns to read lips in order to maintain their previous work and leisure habits for a while. If the work of a person who has lost his hearing is not associated with intensive communication and does not jeopardize his safety, the use of a hearing aid makes it possible to maintain a certain independence in work and leisure (theatre, cinema, television, travel, etc.). The speech disorders described above can also create problems in the area of independent choice of work and leisure, especially in cases where oral speech is a necessary condition for work.
Loss of independence in work and leisure due to chronic diseases leading to disability often changes the habits of the patient. The use of drugs, for example, for the purpose of pain relief, often forces a person to leave work and a previously beloved form of recreation.
"Experiments" with drugs often begin in their free time from study and work. Adolescents want to experience a feeling of excitement, emotional uplift, more vivid sensations than usual. Sometimes, after the first use of a drug, addiction appears, creating physical, psychological, social and legal problems.
Unemployment, like drugs, changes a person's habitual way of life. The loss (absence) of work entails a variety of problems: an excess of free time, idleness, the impossibility of a full-fledged (active) rest due to financial difficulties. If this period is prolonged, a person may lose motivation to find a job that brings pleasure. Apathy and depression force a person to sleep a lot in order to escape from reality. All this leads to a deterioration in health, and more mental than physical. Such a person is restless and preoccupied, quickly loses faith in himself, self-esteem, suffers from sleep disorders. All this predisposes to mental disorders.
Families of the unemployed are also at risk: they are more likely to experience divorces, child abuse, abortions, hypotrophy of newborns, and high infant mortality.
Having identified these problems, the nurse is unlikely to be able to solve them on her own. However, the understanding of the problem and its connection with the disorder of health should cause sympathy for both the patient and his family members.
Changing environment and daily activities also creates problems with work and rest. Of course, a medical institution for a patient is not a place where they work and rest. Problems are often associated with the fact that usually patients are bored by monotony, monotony, often forced (sometimes there is no reason for this) to be in the room all the time. Thus, if a nurse plans to help a person cope with the discomfort caused by a change in the environment, she should, taking into account the nature of work and the usual type of recreation of a person, plan activities that replace usual ones: reading books, magazines, television and radio programs, physical exercises, walks around the territory of the medical institution, etc.
Changing the daily routine often causes anxiety in a person. The lifestyle of an adult is usually determined by his work, or rather, the ratio of time spent on work and rest. In many departments of the hospital there are good reasons for the rigid daily routine, for most patients this gives a sense of calm. It should be remembered that every person is worried about the unknown, so the nurse must necessarily inform the newly admitted patient about the degree of rigidity of the daily routine.
Patients have serious problems due to the inability to independently make decisions regarding their own treatment. Sometimes the staff of a medical institution deprives a person of this opportunity, forgetting that a person in this case loses self-esteem. For example, if adult patients are required to stay in bed during the daytime rest, especially male leaders and women who are used to being the head of the family resist having young sisters make decisions for them and feel uncomfortable in such situations. Thus, the staff often causes a person unnecessary, sometimes harmful to his health, grief. This disrupts the patient's usual role in daily life and does a disservice to the subsequent recovery in professional activities. If possible (the patient's health does not deteriorate, the interests of other patients are not violated), the person can be allowed to continue his work activity. Some patients may need to be told why they should not work while in a healthcare facility. There will definitely be patients who will be delighted with temporary idleness.
Visiting patients with relatives, acquaintances and friends most often helps to smooth out feelings of loneliness and abandonment. F. Nightingale in "Notes on Care" wrote that for small children and the sick, each other's company is ideal. Of course, it is necessary to manage such communication so that none of the participants is harmed, which is quite possible. If there is concern that the air in the room where the patient is present is harmful to the small child, then it is also harmful to the patient. Of course, this needs to be corrected in the interests of both. But the very sight of a baby invigorates a sick person if they do not spend too long together.
Visiting the sick, both children and adults, is very important. Staying outside the family (in a medical institution) traumatizes the patient. However, not always family members are those whom the patient really wants to see. In some cases, the patient needs to be protected from a large number of (or undesirable for him) visitors. Reception days and hours in a medical institution can become stressful for both visitors and patients, and, conversely, can serve as a means to minimize the discomfort caused by the absence of a person in the family.
There are patients who cannot be visited for one reason or another. In these cases, you need to organize communication by phone (if possible) or by mail.
A lonely or elderly patient who is not visited by anyone can be helped by a nurse if she simply takes the time to talk to him when the person expresses a desire to communicate.
When determining the score, it is very important to take into account the patient's opinion about the care provided to him, about the implementation of the plan of care and about the effectiveness of nursing interventions.
Ideally, the final assessment should be performed by the nurse who performed the initial assessment of the patient. The nurse should note any side effects and unexpected results from her planned nursing interventions.
In the event that the goal is achieved, it should be clarified whether this happened as a result of planned nursing intervention or some other factor influenced here.
On the reverse side of the care plan sheet for a specific problem, the current and final assessments of the results of nursing intervention are recorded.
| Date Time | Evaluation (current and final) and comments | Signature |
In determining the effectiveness of nursing intervention, the patient's own contribution, as well as the contribution of his family members, to the achievement of the goal should be discussed with the patient.
RE-EVALUATION OF PATIENT PROBLEMS AND NEW CARE PLANNING
A care plan is only worthwhile and successful if it is corrected and reviewed whenever necessary.
This is especially true when caring for the seriously ill, when their condition changes rapidly.
Reasons for changing the plan:
The goal is achieved and the problem is removed;
The goal has not been reached;
The goal has not been fully achieved;
A new problem has arisen and/or the old problem is no longer so
relevant in connection with the emergence of a new problem.
A nurse, in her ongoing evaluation of the effectiveness of nursing interventions, should continually ask herself the following questions:
Do I have all the necessary information;
Have I correctly prioritized existing and potential problems;
Can the expected result be achieved;
Are the interventions chosen correctly to achieve the goal;
Does care provide positive changes in the patient's condition.
So, the final assessment, being the last stage of the nursing process, is just as important as the previous stages. Critical evaluation of a written care plan can ensure that high standards of care are developed and maintained.
It may seem that the nursing process is a formalism, "extra paperwork". But the fact is that behind all this is a patient who, in a state of law, must be guaranteed effective, high-quality and safe medical care, including nursing. The conditions of insurance medicine imply, first of all, the high quality of medical care, when the measure of responsibility of each participant in this care must be determined: 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 a nurse, every stage of the nursing process is recorded in the nursing history of the disease - a document reflecting the qualifications of the nurse, the level of her thinking, and therefore the level and quality of the care she provides.
Undoubtedly, and world experience testifies to this, the introduction of the nursing process into the work of medical institutions will ensure the further growth and development of nursing as a science, and will allow nursing in our country to take shape as an independent profession.
REMEMBER! When maintaining documentation of the nursing process, it is necessary to:
- document all nursing interventions as soon as possible after their implementation;
- record vital interventions immediately;
- comply with the rules for maintaining documentation adopted by this
medical and preventive institution; - always record any deviations from the norm of the state
the patient; - sign clearly in each column indicated for signature;
- document the facts, not your own opinion;
- be specific, do not use "vague" terms;
- be precise, describe briefly;
- focus on 1-2 issues or important events of the day every day to describe how the situation is different for that day;
- record the factually inaccurate compliance by the patient with the doctor's prescriptions or refusal to do so;
- when filling out the documentation, write down: assessment, problem, goal,
interventions, evaluation of outcomes of care; - do not leave free columns in the documentation;
- record only those interventions that the sister has performed.
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