The vocation of a nurse is to assist an individual in all matters that relate to his he alth or restoration of he alth, as well as the onset of a painless death. The activity of a specialist should be aimed at teaching a person to cope without any help from outsiders, giving him complete information so that he can become independent more quickly. In nursing, there is a special technology called the nursing process. It aims to improve the quality of life of patients by solving the difficulties that they have. Today we will talk about how the problems of the patient are identified and solved in the nursing process.
Nursing process goals
The nurse must guarantee an acceptable quality of life for the patient, depending on the condition in which he is. The patient's problem must be prevented, alleviated and minimized. If a person has an injury or a certain disease, the nurse is obliged to help him and his family adapt to new living conditions. Patient autonomy and autonomy must beachieved and maintained, his basic needs must be met or ensured a peaceful death.
Steps in the nursing process
The nursing process is step by step. The first step is to examine the patient. Then - the establishment of the patient's problem (nursing diagnosis). After that, planning of nursing care for the patient takes place, the implementation of plans to solve the patient's difficulties and the evaluation of performance with subsequent correction. Today we will look at the second step of the nursing process.
Nursing diagnosis
In order to identify the patient's difficulties, an individual care plan is developed so that the patient and his family can adapt to the changes that have arisen due to he alth problems. The nurse must first find out the needs of the patient, which he himself cannot satisfy, which leads to the formation of difficulties. The nurse performs nursing diagnosis of the patient's condition. In this case, the problems of the patient are clarified. Here, a medical judgment is formed, which describes the form of the patient's response to his illness and condition, indicating the cause of this reaction. In this case, much depends on the type of disease, changes in the external environment, medical procedures, living conditions of the patient, as well as on his personal circumstances.
Types of patient problems
Nursing process does not take into account the disease, but reactionspatient on his condition and disease. Such reactions can be of several types:
- Physiological. They are characterized by processes occurring in the patient's body. This could be, for example, stool retention.
- Psychological. These reactions are driven by anxiety and lack of awareness about the disease and downplaying the severity of the disease.
- Spiritual reactions can be manifested in the desire to die with an incurable disease, in disagreements with the family that arise due to illness, the choice of life values, and so on. Therefore, it is important to correctly identify the problems of the patient and relatives when caring for a seriously ill patient.
- Social. They are characterized by a desire to isolate themselves in the presence of a deadly infectious disease.
A nurse is not always able to solve all of the above difficulties. Therefore, in practice, they are usually divided into psychosocial and physiological.
Existing and potential problems of the patient
All the problems of the patient and relatives in the first hours of hospital stay are usually divided into existing ones, those that are currently available, and potential ones, presented in the form of further complications, which can be prevented with a properly planned nursing process. Almost always, the patient has several types of difficulties, so they are all divided into priority and secondary. to priorityproblems include:
- emergencies;
- quite painful problems for the patient;
- problems that can lead to complications;
- difficulties on the solution of which a positive result of treatment depends;
- those that limit the patient's ability to care for themselves.
In nursing diagnosis, it is necessary to take into account all the difficulties of the patient, which can be resolved or corrected by the medical staff. They are distributed by weight and proceed to the decision, starting with the most important. By setting priorities among the problems of the patient and relatives in the first hours in the hospital, you can use the pyramid of needs according to A. Maslow. This technique allows you to highlight the primary needs, intermediate and secondary.
Principles of nursing diagnosis
For the analysis to be useful and focused, the following principles must be observed:
- Identification of needs that the patient cannot satisfy on their own.
- Identification of the factors that cause disease.
- Identification of the patient's strengths and weaknesses that contribute to either development or prevention of difficulties.
- Predict the further possibilities of the patient, their expansion or limitation.
Difficulties in making a nursing diagnosis
A nurse can express those difficulties, the resolution of which does not go beyond her authority. Tounderstand the accuracy of the patient's problem statement and the correct nursing diagnosis, it is recommended to check the following:
- Does the problem relate to a lack of self-service. For example, the difficulty of breathing in a certain position of the patient is associated with a lack of self-care. She can be taken care of by a nurse.
- To what extent the diagnosis is clear to the patient.
- Will nursing diagnosis become the basis for planning nurse maneuvers. The intervention of a specialist will be correct if he finds out the cause that causes a certain condition of the patient.
- Will the difficulty she identified become the patient's problem.
- Does the nurse's diagnosis include only one patient's problem. It is necessary to single out several diagnoses, and also take into account the fact that the patient does not understand what worries him. For example, the problems of a patient with shigellosis may be related not only to the disease, but also to treatment, the situation in the hospital, family relationships, and so on.
The task of diagnosing a nurse is to identify all the existing or expected difficulties of the patient on the path to restoring his good condition, determining the most painful problem at the present time, forming a diagnosis and planning measures to care for the patient.
Content of the nursing process in the second stage
The patient should help the nurse correctly identify the main thing when posing the patient's problem. All inconsistenciesmay disappear by discussing issues with the sister and the patient. If there are serious psychological and emotional difficulties, the he alth worker takes responsibility for the selection of primary diagnoses. When a patient has just been admitted to the hospital or he has an unstable condition, the problems of the patient and relatives in the hospital are not immediately determined, this is done only after studying all the information, since conclusions made ahead of time provoke an incorrect diagnosis and poor nursing care. Often there are cases when the problem of the patient cannot be established. In this case, the usual statement of symptoms is carried out. In other cases, the disease is caused by adverse life situations. Then the nurse explains all these circumstances in detail. In this case, she will be able to help the patient as much as possible to overcome the negative consequences.
Results
At the second stage of the nursing process, the analysis of the data that was obtained at the first stage during the examination of the patient takes place. Here, the medical staff must identify, for example, the problems of the patient and relatives during different periods of fever, and formulate accurate diagnoses that prevent the patient from achieving a positive state, as well as those that the nurse can solve. It must be borne in mind that the patient's difficulty may be related not only to the disease, but also to the methods of treatment, the environment, relationships with relatives, and so on. Nursing diagnoses canchange not only every day, but throughout the day.
You need to remember that they are different from medical diagnoses. The doctor diagnoses and prescribes treatment, and the nurse helps the patient to adapt and live with the disease. One ailment of a person can cause a lot of difficulties for him, so there can be a certain number of nurse diagnoses. It is important to remember that, unless there are immediate physical disorders, the patient's life may be endangered by the failure to meet his or her psychosocial needs. Setting priorities in the diagnosis, the nurse has the right to involve the relatives of the patient. At the same time, it should indicate the reasons that led to the emergence of problems, as well as direct its actions to eliminate them. All nursing diagnoses are recorded in the Nurse Care Plan (NCP).
