Method of organization and practical implementation by a nurse. Nursing process is a method of organizing and delivering nursing care. Patient data
The results of a study by WHO / Europe show:
“The essence of nursing is caring for a person and how the sister provides that care. This work should be based not on intuition, but on a thoughtful and well-formed approach designed to meet needs and solve problems ... ”.
The nursing process brings a new understanding of the role of a nurse in practical health care, requiring from her not only good technical training, but also the ability to be creative in caring for patients, the ability to work with the patient as a person, and not as a nosological unit, an object of "manipulative technology ". The nursing process is based on the patient as a person requiring an integrated (holistic) approach. One of the prerequisites for the implementation of the nursing process is the participation of the patient (family members) in making decisions about the goals of care, the plan and methods of nursing intervention. The outcome of the care is also assessed jointly with the patient (family members). The degree of patient involvement in the nursing process depends on several factors:
- the relationship between the sister and the patient, the degree of trust;
- the patient's attitude to health;
- level of knowledge, culture;
- awareness of the need for care.
The constant presence and contact with the patient makes the nurse the main link between the patient and the outside world. The patient wins the most in this process. The outcome of the disease often depends on the relationship between the nurse and the patient and their mutual understanding.
The patient's participation in this process allows him to realize the need for self-help, learn it and evaluate the quality of nursing care.
The word "process" means progress, the course of events, in this case, sequential actions, steps taken by a sister to achieve a certain result.
In the WHO Nursing and Midwifery Program in Europe, the nursing process is described as follows:
“Nursing process is a term used in a system of characteristic types of nursing interventions in the field of health care of individuals, their families or groups of the population. Specifically, it involves the use of scientific methods to determine the health needs of the patient / family or community and, on this basis, the selection of those that can be most effectively met through nursing care. It also includes planning responses to meet appropriate needs, organizing care, and evaluating results. The nurse, in collaboration with other members of the healthcare team, identifies tasks, priorities, type of care needed, and mobilizes the necessary resources. She then provides nursing assistance directly or indirectly. After that, she evaluates the results obtained. The information gained from evaluating the results should form the basis for necessary changes in subsequent interventions in similar nursing situations. Thus, nursing turns into a dynamic process of their own adaptation and improvement. "
Thus, based on scientific principles, nursing process provides a clear pattern of actions for the nurse to achieve professional goals. In other words, nursing process means a sequential change in the actions performed by the nurse in relation to the patient in order to prevent, alleviate, reduce and minimize the problems and difficulties that arise.
Need
1) the need to breathe -
2. There is a need -
3. Need to drink -
4. The need to isolate -
6. The need to be clean.
11 the need to move
12. The need to communicate.
Fourth level. Self-esteem is the achievement of success.
The need for respect, self-esteem - here we are talking about respect, prestige, social success. It is unlikely that these needs are met by an individual; it requires groups.
13. Need for success. Communicating with people, a person cannot be indifferent to the assessment of his success from others. A person develops a need for respect and self-respect. The higher the level of socio - economic development of a society, the more fully the needs for self - esteem are satisfied.
Fifth level. Self-realization, service. The need for personality development, for fulfilling oneself, for self-realization, self-actualization, for understanding one's purpose in the world.
The need to play, study, work- this is the highest level of human needs. It is necessary for self-expression, self-realization. A child realizes himself in play, an adult in work. To do this, he needs to learn, improve.
Needs influence the feelings, the will of a person, form the orientation of the personality. The dominant need suppresses the rest of the needs, determines the main direction of human activity. Man consciously regulates needs and this is different from animals.
In 1977, the hierarchy of human needs, according to A. Maslow, is undergoing changes. As a result of these changes, the number of levels of the pyramid increases to 7, cognitive, aesthetic needs appear, and the list of needs changes.
Virginia Henderson, developing her model of nursing in the mid-60s of the last century, was based on A. Maslow's theory of the hierarchy of basic human needs. The needs according to V. Henderson are significantly less at each level than according to A. Maslow.
V. Henderson suggests 14 needs for daily life:
1. Breathe normally
2. Eat adequate amounts of food and liquids
3. Allocate waste products from the body
4. Move and maintain the desired position
5. Sleep, rest
6. Dress and undress yourself, choose clothes
7. Maintain body temperature within normal limits by choosing appropriate clothing and changing the environment
8. Observe personal hygiene, take care of appearance
9. Ensure your safety and do not endanger other people
10. Maintain communication with other people, expressing their emotions, opinions
11. Conduct religious practices in accordance with your faith
12. Do your favorite job
13. Rest, take part in fun and games
14. Satisfy your curiosity, which helps to develop normally
History of the issue.
The concept of nursing was born in the United States in the mid-50s of the last century. Currently, it has received widespread development in the American and Western European models of nursing.
The purpose of the nursing process.
Nursing process- it is a scientific method for organizing and delivering nursing care, a systematic way of identifying the situation of the patient and the nurse and the problems that arise in this situation, in order to implement a care plan that is acceptable to both parties. The nursing process is a dynamic, cyclical process.
The purpose nursing process is the maintenance and restoration of the patient's independence in meeting the basic needs of the body, requiring an integrated (holistic) approach to the patient's personality.
7. The advantages of introducing the nursing process into nursing education and nursing practice.
The nursing process provides:
1. Systemic, i.e. a carefully thought-out and planned approach to the organization of nursing care.
2. An individual approach and organization of nursing care, taking into account all personal characteristics of the patient and the originality of a specific clinical situation.
3. Active participation of the patient and his family in planning and providing care.
4. Possibility of widespread use of professional standards.
5. Effective use of the nurse's time and resources, focusing on the patient's underlying problem.
6. Increasing the competence, independence, creative activity of the nurse, and hence the prestige of the profession as a whole.
7. The versatility of the method.
8.The stages of the nursing process, their relationship and a summary of each stage.
¾ First stage: nursing examination.
Nursing examination or situation assessment to determine the specific needs of the patient and the resources needed for nursing care. This stage includes the process of collecting information for assessing the situation using the methods of nursing examination.
There are the following examination methods: subjective (the patient's own opinion and the opinion of his non-medical environment about the state of health), objective (professional representation of the medical environment about the patient's health) and additional methods to determine the patient's needs for care (collection of additional information about the psychological, spiritual status of the patient etc.).
The foundation of nursing examination is the doctrine of the basic vital needs of a person.
The collection of the necessary information begins from the moment a patient is admitted to a hospital or seeking medical help until recovery.
In order to determine the priority (according to the degree of threat to life) violated needs or problems of the patient, the degree of independence of the patient in care, the collected information is analyzed.
¾ Second stage: identification of patient problems or nursing diagnosis.
Nursing diagnosis this is the patient's state of health (current or potential), established as a result of a nursing examination and requiring intervention from the nurse.
The analysis of the information obtained at the first stage is the basis for formulating the patient's problems (nursing diagnoses), existing (real, explicit) or potential (latent, which may appear in the future). When determining priority, a nurse should rely on a medical diagnosis, know the patient's lifestyle, risk factors that worsen his condition, remember his emotional and psychological state. In terms of priority, the patient's problems can be primary, intermediate, or secondary.
Objective examination of the patient includes somatoscopic, self-metric and physiometric studies. The examination of the patient begins with a general examination. For a nurse, the objective research method is essential, as it provides the most complete objective information about the patient.
Somatoscopic examination - This is an examination of the patient, in which deviations from the norm are detected.
General examination of the patient
| Inspection sequence | Evaluation criterion |
| I. Inspection in general | |
| 1. General condition | - satisfactory - moderate - severe - extremely severe |
| 2. Consciousness | - clear - disturbed (darkened, stupor, stupor, coma, fainting) |
| 3. Position | - active - passive - forced |
| II. Inspection in parts | |
| 1.Head | - shape (correct, asymmetric) - size (medium size, large, microcephaly) |
| 2.Face | - oblong - oval - round - symmetrical - asymmetrical |
| 3 facial expression | - facial expressions saved - absent (mask-like face) |
| 4 eyes | |
| 5.Neck | - normal shape - deformed - long - medium length - short - neck circumference - thyroid gland (examination and palpation) |
| 6.Constitution (physique) | |
| III. Research "outside in" | |
| 1 leather and its derivatives | |
| 4.Joints | |
| 5 the eyes | - eye shape - width of the palpebral fissure - blinking frequency - pupils (wide, narrow, reaction to light) - strabismus (converging or diverging squint) - color - sclera |
| 6.Neck | - normal shape - deformed - long - medium length - short - neck circumference - thyroid gland (examination and palpation) |
| 7.Constitution (physique | - normosthenic - asthenic - hypersthenic |
| IV. Research "outside in" | |
| 1 leather and its derivatives | - color (white, pale pink, pink, red, yellow, swarthy, earthy, brown, dark brown, variegated, cyanotic, albinism) - humidity (normal, increased, decreased, hyperelasticity) - turgor (normal, decreased, hyperelastic ) - temperature to the touch (normal, high, low) - rashes (localization, size of elements, character, other pathological elements, etc.) - focal hyperpigmentation, dyspigmentation - scars (localization, length, width, adhesion with underlying tissues, shape, character) - external tumor formations (atheroma, angioma, warts, etc.) - nails (shape, color, shine, surface deformation, fragility, stratification, edge character) - hair (thick, sparse, baldness, hair graying, increased fragility, dropping out) |
| 2.Mucos (eyes, eyelids, nose, lips, mouth) | - color (white, pale pink, cyanotic, icteric, red, etc.) - rash on mucous membranes (enanthema) - localization - size - character |
| 3.Subcutaneous fatty tissue | - the severity of the subcutaneous fat layer (absent, poorly developed, satisfactory, moderate, excessive) - uniformity of distribution (general obesity, cachexia, places of local deposition or disappearance of fat) - edema, their consistency (soft, dense), severity (pasty, moderate pronounced, pronounced), distribution (face, limbs, abdomen, lower back, general edema - anasarca), skin color over the edematous tissue (pale, cyanotic), to control the dynamics of edema, determine the depth of the fossa from pressure, the circumference of the leg, thigh, shoulder etc. - soreness of subcutaneous adipose tissue under pressure, crunching sensation (with subcutaneous emphysema) - subcutaneous formations (adipose tissue, tumors, etc.) |
| 4.Joints | - examination of symmetrical joints of the limb (shape, swelling, hyperemia of the skin over the joints) - range of motion in the joints (full, limited mobility, excessive mobility) - degree of mobility of the spine in the cervical, thoracic and lumbar regions, stress symptom. |
The examination of the patient is carried out by the nurse sequentially, starting with an external examination, which is carried out in diffused daylight or bright artificial lighting. The light source should be on the side, so the contours of various parts of the body are more prominently distinguished.
Physiometric measurements
They include anthropometry, determination of the value of blood pressure, counting the pulse, respiration, measuring body temperature, identifying edema.
Anthropometry Is a set of methods and techniques for measuring the human body.
Conducting anthropometry, the nurse often measures the body weight, height of the patient and the circumference of the chest.
Body weight is determined (if the patient's condition allows) upon admission to the hospital, and then necessarily every 7 days or more often (as prescribed by a doctor). Measurement data of body weight is recorded in the temperature sheet of the medical history.
Height measured using a stadiometer. The domestic industry produces wooden and metal rosometers combined with scales.
Measurement of the chest circumference is carried out with a soft centimeter tape in three positions:
1. At rest
2. With full inhalation
3. At maximum exhalation
Body mass in a hospital, it is determined using medical scales under the same conditions: in the morning, on an empty stomach, after emptying the bowels and bladder, the patient must be in the same light underwear. The measurement is carried out according to a specific algorithm.
To characterize your weight most accurately, you should calculate the so-called body mass index (BMI)... It is calculated in this way. Body mass index = weight, kg: (height, mx height, m):
Square your height in meters, not centimeters (i.e. 170 cm = 1.7 m) (1.7 x 1.7 = 2.89).
Divide your body weight in kilograms (90 kg) by the resulting number: 90: 2.89 = 31.1. The number "31.1" will just be your body mass index.
Compare the obtained body mass index with the table below, where their assessment is given opposite the body mass index values.
For example, the man from the described example is 170 cm tall and weighs 90 kg has a body mass index of 31.1, which immediately allows him to be diagnosed as obese and advise him to change his diet and increase physical activity (see below).
Interpretation of an individual body mass index
Breath monitoring
Observing the patient's breathing, the nurse must be able to determine the rhythm, frequency, depth of breathing movements and assess the type of breathing.
Normal respiratory movements are rhythmic.
The respiratory rate (RR) in an adult at rest is 16-20 per minute. And in the supine position, the number of respiratory movements usually decreases (up to 14-16 per minute). In trained people and athletes, the respiratory rate can decrease and reach 6-8 per minute.
An increase in NPV of more than 20 respiratory movements per minute - tachypnea.
Reduction of NPV less than 16 per minute - bradtpnea.
Shallow breathing is usually observed at rest, and with physical or emotional stress, it is deeper.
Depending on the predominant participation in the respiratory movements of the chest or abdomen (diaphragm), there are:
Thoracic (more common in women)
Mixed breathing patterns
Breathing should be monitored unnoticed by the patient, as he can arbitrarily change the frequency, depth and rhythm of breathing.
If the satisfaction of the need to "breathe" is not met, the patient may experience shortness of breath.
Depending on the difficulty of one or another phase of breathing, shortness of breath can be:
Inspiratory (when breathing is difficult)
Expiratory (difficult exhalation)
Mixed (with difficulty in both inhalation and exhalation)
In addition, shortness of breath should be distinguished:
Physiological (arising with significant physical or emotional stress)
Pathological, arising from diseases of the respiratory system, bleeding, cardiovascular system, as well as poisoning with certain poisons.
All results of the patient's nursing examination are recorded in the EXPERIMENTAL nursing card of the inpatient (the name of the document is conditional).
Self-study questions:
1.What is blood pressure (BP)?
2. What types of pressure do you know?
3. What are the normal blood pressure indicators?
4.What is pulse pressure?
5. What is the name of the increase in blood pressure?
6. What is the name of lowering blood pressure?
7. List the reasons causing the increase in blood pressure.
8. Name the apparatus used to measure blood pressure.
9. Violation of what needs can affect blood pressure indicators?
10. How timely detection of high blood pressure indicators can affect the course of the disease and the state of health?
11. Give a definition of the concept of "pulse".
12. What are the places where the pulse was measured?
13. Give a characteristic of the qualities of the pulse:
Frequency;
Filling;
Voltage;
Magnitude;
Symmetry.
14. What is “pulse deficit”?
15. List the organs involved in the act of breathing.
16. What is determined by observing breathing?
17. What types of breathing do you know?
18. What kind of deep breathing is there?
19. What is the rate of NPV is normal.
20. What is the name of rapid breathing?
21. What is the name of slow breathing?
22. What is apnea?
23. What types of shortness of breath do you know?
24. In what cases does physiological shortness of breath occur?
25. In what cases is pathological shortness of breath observed?
26. List the methods for determining edema.
27. Name the cause of edema.
28. What are the normal indicators of body temperature?
29. List the rules for measuring body temperature.
30. What is a "temperature profile"?
31. List the equipment used to measure temperature.
32 .. Name the documentation for recording the received data.
Self-study assignments
1. Get to know the device of the tonometer, sphygmomanometer, electronic tonometer.
2. Practice the technology for measuring blood pressure. Describe the received data.
3. Familiarize yourself with the structure of the temperature sheet.
4. Practice the technology of measuring the pulse on the radial, carotid arteries. Describe the received data.
5. Calculate the NPV.
6. Differentiate inspiratory and expiratory dyspnea.
7. Get to know the device of a mercury thermometer.
8. Take a temperature measurement in the armpit, rectum.
9. Carry out registration of the obtained data of blood pressure, pulse and temperature in the temperature sheet.
Topic 1.1.4. Nursing process as the basis of nursing care
1. Levels of basic human needs according to A. Maslow and the needs of everyday life according to V. Henderson.
Need is a conscious psychological or physiological deficit of something, reflected in the perception of a person, which he experiences throughout his life and must fill it in order to achieve health and well-being.
American psychophysiologist of Russian origin Abraham Maslow in 1943 identified 14 basic human needs and arranged them according to five levels. According to his theory, which determines human behavior, some needs for a person are more essential than others. This made it possible to classify them according to a hierarchical system - from physiological to needs for self-expression. Arranging the needs of a person in the form of a pyramid, A. Maslow showed that without satisfying the lower, physiological needs that lie at the base of the pyramid, it is impossible to satisfy the higher needs.
The first level of human needs. Physiological basic needs. Survival. These are the lower needs controlled by the organs of the body, such as breathing, food, sexual, the need for self-defense.
1) the need to breathe - provides constant gas exchange between the cells of the body and the environment. This is one of the basic physiological needs of a person. Breathing and life are inseparable concepts. A person, satisfying this need, maintains the blood gas composition necessary for life.
2. There is a need - provides the body with the nutrients it needs to stay healthy. Rational and adequate nutrition helps to eliminate risk factors for many diseases.
3. Need to drink - satisfying the need to drink, a person delivers water to the body to maintain water - salt metabolism.
4. The need to isolate - ensures the removal of waste products, toxins, substances harmful to the body.
5. The need to sleep, to rest - the satisfaction of this need ensures the restoration of the depleted nervous system and the disturbed functional state of the body, thereby normalizing the physical and mental activity of a person.
Second level. Reliability needs - safety- striving for material security, health, ensuring old age, etc. To achieve this, some needs must be satisfied.
6. The need to be clean. The skin and mucous membranes of a person perform a protective function, remove waste products from the body, and participate in thermoregulation processes. Therefore, a person needs to take care of maintaining the purity of the body.
7. Need to dress, undress. Depending on the state of the body and climatic conditions, a person needs to maintain and regulate body temperature with clothing, ensuring a comfortable state of the body, regardless of the season. For this, it is important to choose clothes by age, gender, season, environment.
8 the need to maintain body temperature... A constant body temperature (within the limits of physiological fluctuations) is created by the process of thermoregulation, as a result of which a balance between heat production and heat transfer is maintained in the body. For this, it is necessary to maintain the microclimate in the premises where the person is and control the choice of clothing for the season.
9 the need to be healthy - is ensured by a person's desire for independence in meeting vital needs when the state of health changes, the onset of an illness, for an independent solution of many problems, for active participation in the chosen course of treatment or rehabilitation.
10. The need to avoid danger, disease, stress - provides a person with the avoidance of risk factors that lead to the occurrence of diseases. It is important to avoid indifference to your health condition.
11 the need to move- Provides appropriate blood circulation in the body, thereby improving tissue nutrition, increasing muscle tone, and facilitating the resorption of stagnation.
Third level. Social needs. Affiliation- these are needs for family, friends, their communication, approval, affection, love, etc. Meeting the needs of this level is biased and difficult to describe. One person's need for communication is expressed very strongly, the other is limited to very few contacts. Helping a person solve a social problem can significantly improve the quality of his life.
12. The need to communicate. Communication as a complex, multifaceted process of establishing contacts between people, generated by the needs of joint activities, is necessary for the patient for normal life, especially psychoemotional balance. Violation of a person's social contacts can lead him to isolation, the desire for self-isolation, or, conversely, to irritability and increased demands on himself.
1. The method of organization and practical implementation by the nurse of her duty to serve the patient:
A) diagnosis of diseases
B) the treatment process
C) nursing process
D) disease prevention
2. The second stage of the nursing process:
A) nursing examination
C) planning the scope of nursing intervention
D) identifying nursing care problems
3. Evaluation of the nursing process allows you to determine:
A) speed of nursing care
B) the duration of the illness
C) quality of nursing care
D) the causes of the disease
4. Subjective method of nursing examination:
A) questioning the patient
B) definition of edemas
C) measurement of blood pressure
D) examination of the patient
5. The third stage of the nursing process:
A) examination of the patient
B) identifying the patient's problems
D) drawing up a care plan
6. The purpose of the first stage of the nursing process:
A) examination of the patient
B) drawing up a care plan
C) performing nursing interventions
D) assessment of the quality of nursing care
7. Nursing process - a method of organizing the provision of care:
A) urgent
B) medical
C) nursing
D) clinical
8. Assessment of the patient's condition - stage of the nursing process:
A) first
B) second
C) third
D) fourth
9. The nurse determines the needs of the patient during the period:
A) examination of the patient
B) setting care goals
C) determining the scope of nursing interventions
D) implementation of the nursing intervention plan
10. Conversation with the patient - examination method:
A) objective
B) subjective
B) additional
D) clinical
11. Measurement of height and body weight - examination method:
A) subjective
B) objective
B) additional
D) clinical
12. Research of NPV, pulse, blood pressure - method of patient examination:
A) additional
B) objective
C) clinical
D) subjective
13. Physiological units assess the patient's condition:
A) emotional
B) psychological
C) social
D) physical
14. Anthropometric research includes the definition of:
A) body weight
B) temperature
15. Mobility - the patient's condition:
A) mental
B) physical
C) social
D) spiritual
16. Increase in blood pressure is:
A) hypotension
B) hypertension
C) tachycardia
D) bradycardia
17. Tachypnea is:
A) decrease in heart rate
B) reduction of breathing
C) increased heart rate
D) increased breathing
18. Increased heart rate:
A) tachypnea
B) bradypnea
C) tachycardia
D) bradycardia
19. Priority physiological problem of the patient:
B) anxiety
C) weakness
D) lack of appetite
20. Incomplete patient information - problem:
A) valid
B) intermediate
B) potential
D) temporary
21. Unsatisfied patient problems:
A) desires
B) abilities
C) opportunities
D) needs
22. Documenting the first stage of the nursing process - a condition:
A) continuous
B) optional
B) mandatory
D) temporary
23. Documentation of the stages of the nursing process is carried out in:
A) the patient's medical record
B) outpatient card
C) the assignment sheet
D) nursing appointment history
24. Laboratory research data - source of information:
A) primary
B) subjective
B) additional
D) main
25. Performing nursing interventions - SP stage:
A) first
B) second
C) third
D) fourth
26. Social problem of the patient:
A) conflict in the family
Nursing process is a scientific method of organizing and providing nursing care, implementing a plan for caring for therapeutic patients, based on the specific situation in which the patient and the nurse are. The care plan is drawn up by the nurse in consultation with the patient to solve his problems.
The purpose of the nursing process is to maintain and restore the patient's independence in meeting the basic needs of the body in accordance with the daily needs of a person in his daily activities developed by the American psychologist A. Maslow and modernized by V. Henderson. The nursing process is a systematic, well thought out, goal-oriented nurse action plan that takes into account the needs of the patient. After the implementation of the plan, it is imperative to assess the results. The standard nursing process model has five steps. The first stage is a medical nursing examination of the patient, determining the state of his health. The second stage is the formulation of a nursing diagnosis. The third stage is the planning of the nurse's actions (nursing manipulations). The fourth stage is the implementation (implementation) of the nursing plan. The fifth stage is an assessment of the quality and effectiveness of the nurse's actions.
The advantages of the nursing process: versatility of the method; providing a systematic and individual approach to nursing care; wide application of professional standards; ensuring high quality of medical care, high professionalism of a nurse, safety and reliability of medical care; caring for the patient, in addition to medical workers, is attended by the patient himself and his family members.
Until recently, the principle of a nurse's activity was based on a clear and "automatic" fulfillment of doctor's prescriptions, without taking into account issues related to any mental experiences of the patient. For this, a nurse should have not only knowledge in terms of patient care, but also awareness of the basic issues of philosophy and psychology. Because the nurse devotes much of her work to educating patients, she needs pedagogical competence. Currently, there are significant shortcomings in the organization of the nursing process, associated primarily with misunderstanding and ambiguity in many definitions. Nurses sometimes speak to each other in “different languages”, in contrast to doctors who have generally accepted definitions. The organization of the nursing process is based on the model of W. Henderson. Nursing structure is the elements of scientific knowledge applied by a nurse to organize and deliver patient care. It is a continuous, constantly evolving system that has certain stages. The nursing process is aimed at preserving and successfully rehabilitating the patient's health after suffering a violation of needs. To do this, the nurse must resolve several issues.
The first question is the organization of a certain basis, which includes complete information about the patient. The second task for the nurse is to identify the impaired needs in the patient. Next, you need to determine the priority actions that need to be taken in relation to the patient. The next points are the implementation of the planned activities and the analysis of the work done by the nurse. The above questions are the main stages of the nursing process. The activity of a general nurse in the structure of providing primary care to citizens of our country is based on the standards of the nursing process, although it has its own characteristics.
The first stage of the nursing process includes diagnostic measures for one or another impaired need for the disease. The second element is prioritization. In this case, the family nurse draws up a list of the information received by talking with the patient or his relatives by the method of questioning, and also applies the data received from the medical staff and from accompanying documents. The first stage of the nursing process involves the use of certain methods of collecting information about the patient. The main one is the compilation of a list of subjective information, which includes the patient's complaints (major and minor). Then the nurse collects objective information, which includes the patient's anthropometric data, state of mind, skin. Here she examines the cardiovascular and respiratory system according to the main parameters - pulse, arterial pressure, spirometry, etc. An important element of the family nurse's activity is the analysis of the patient's mental state, ethnic characteristics. It is also necessary to pay attention to the industrial facilities located near the house, the working and educational conditions of each family member. It is also important to carefully observe the behavioral reactions of the interviewed clients and their emotions at the same time. The general practitioner carries out the compilation of a list of patient data constantly and continuously in her work with this family.
The second stage of the patient's nursing process is the assessment of the collected information, aimed at identifying the main impaired needs. The success of a family nurse at this stage depends on the knowledge and experience of her professional communication with the patient, as well as the application of the basic positions of medical deontology and ethics. She must immediately and competently analyze the patient's condition in order to move on to the second stage of her activity - the formulation of a nursing diagnosis. A general practitioner nurse working in the primary care service, at this stage, must accurately and competently determine the diagnosis of the population according to the needs, the satisfaction of which is impaired for the residents of this area, but for one reason or another. Then she identifies the priority problem of the population (disease) and carefully analyzes the elements of its solution. For this, the nurse often uses the basic indicators of the health of the population. These include the total number of diseases, deaths, the quality of the treatment and prophylactic measures, and the source of material support is also important.
To analyze the corresponding indicator separately, a five-point scale is used. Following the establishment of a priority problem for citizens of a certain territory, a nurse forms groups of them depending on gender, age, and the presence of elements of increased danger. The activity of a nurse in relation to a particular family is similar and involves the identification of problems of clients, divided into two groups. The first group consists of the present, the second - the future problems of the patient. Identifying the main problems, the family nurse must adhere to the diagnostic order of the doctor, have certain information about the patient's vital functions, elements of increased danger to his health, as well as his intrapersonal characteristics. The work of a nurse at this stage has a great responsibility, since a favorable outcome of his disease depends on the conclusions she makes about the patient's condition. The diagnosis made by the nurse should reflect the impaired need of the patient and the cause that caused it. Examples of nursing diagnoses: urinary dysfunction due to inflammatory kidney damage and fear due to upcoming surgery. The diagnostic decisions of the family nurse characterize the problems in various areas of the patient's life - from the disturbed need for nutrition to the need for his self-realization in society. Unfortunately, the relevant organizations involved in the nursing process have not established a generally accepted list of nursing diagnoses, but only an approximate list of them.
The third stage of the nursing process involves setting goals for the family nurse. This work must be carried out sequentially, i.e. one should begin with the solution of the main problem of the patient. The need to determine the goals of nursing is due to the individual personal and physiological characteristics of patients, as well as the establishment of the level of quality of the work done. The family nurse should actively involve the patient in the work in setting goals and methods of obtaining them, which will provide him with motivation for a favorable outcome of the disease.
There are two types of goals, the first of which should be completed in the next week, and the second - at a later date. A separate goal consists of three elements: action, time, and the "tool" for achieving the goal. Further, a thorough analysis of the existing issues is carried out, followed by the approval of an appropriate action plan in each specific case. After that, the medical staff implements their plans, followed by a critical analysis of the work performed. To better understand the stages of a nurse's activity, it is necessary to describe each stage in detail. Example of a long-term goal: The patient will be able to participate in athletics two months after discharge from the hospital. An important element in the activities of a family nurse at this stage is the setting of goals that meet certain needs. Target statements should be achievable, accurate in terms of implementation.
The fourth stage of the nursing process involves planning the activities of a nurse. In the system of providing primary care to the population, this stage includes the choice of the area of nursing work, the establishment of its indicators and the creation of an intervention program, which is reflected in the corresponding document. Then, the division of functions between the participants of this service is carried out and a personal data recording structure and control system are organized. The family nurse's activity at this stage consists in writing instructions, where she lists in detail the preventive and curative actions performed in relation to her clients.
There are several types of nursing work. The dependent species includes the work of the sister, which is to follow the doctor's recommendations and under his supervision. An independent view involves the independent activity of a nurse. These actions include: systematic monitoring of vital health indicators, emergency care before the arrival of the doctor, ensuring personal hygiene of seriously ill patients, measures to prevent the spread of infectious diseases in the department, etc. measures for the care and treatment of patients. This activity includes preparatory manipulations for various types of hardware and laboratory diagnostics. This also includes a consultation with a physical therapy and physiotherapy doctor.
At this stage, the nurse must determine the ways of implementing her activities, which are formulated according to the patient's problems. These include: the implementation of emergency assistance before the arrival of the doctor, the implementation of his recommendations, ensuring favorable living conditions for the patient, assistance in the event of physiological and psychological problems, measures to prevent complications of the disease and the organization of consultations for family members. Then the nurse performs a set of planned activities in accordance with the stated goals. There are certain conditions, under the strict presence of which a nursing plan is suitable for implementation. These include the constant implementation of planned actions, as well as the active participation of family members in their implementation. These actions may not be carried out in case of unforeseen situations. When undertaking emergency activities, it is necessary to use certain templates that are specially designed for nursing practice. An important point is the attention of the nurse to the subjective characteristics of the patient. Nursing actions are recorded in a special form, taking into account the frequency, time of their execution, and also the patient's reaction to the measures taken is noted there.
In the activities of a general nurse in the primary care service to the population, at the stage of implementation of the planned activities, much attention is paid to clear guidance of actions. At the same time, the favorable success of this stage depends on clearly set goals, strictly planned actions, as well as the availability of appropriate means of achieving positive results. Essential components of the correct execution of the planned work are a clear division of functions between the participants in this activity, their good awareness of certain information and loyalty to their work.
The fifth stage of the nursing process involves analyzing the activities of the nurse and, if necessary, taking corrective actions. This stage also includes comparative conclusions of nursing activities with the goals set. In case of a favorable result, the family nurse records this in a special form with an exact indication of the time parameters. In the opposite case, when the patient needs nursing care, a careful analysis of the nurse's actions should be carried out to find out the cause of this situation. To do this, you can use the advice of other specialists in order to competently plan your work. These measures ensure the effectiveness of nursing, the study of the patient's response to the appropriate manipulations, and also make it possible to determine other disturbed needs of the client. An important characteristic of a nurse in the implementation of quality work at this stage is the ability to make a comparative analysis of the results obtained with the goals set. Corrective measures can be taken only in the presence of adverse changes in the patient's state of health.
Toolkit
Theme: " Nursing process for pain»
Methodological manual on the topic "Nursing process in pain» according to MDK.04.01 "Theory and practice of nursing" is intended for the student to master the main type of professional activity (VPA) - solving the patient's problems through nursing care and the correspondingprofessional competencies (PC):
- Communicate effectively with the patient and his environment in the course of professional activities.
- Comply with the principles of professional ethics.
- Advise the patient and those around him on nursing and self-care issues and
general competences (OK):
- To understand the essence and social significance of your future profession, to show a steady interest in it.
- Analyze the working situation, carry out current and final control, assessment and correction of their own activities, be responsible for the results of their work
- Search for information necessary to effectively perform professional tasks
- Work in a team, communicate effectively with colleagues, management, consumers
The student should be able to:
- Carry out the nursing process for pain;
- Conduct an initial assessment of pain using various types of scales;
- Draw up a nursing intervention plan for a specific patient;
- Evaluate the result of nursing interventions
The most important and most difficult issue is the objectification of the pain sensation.
It is well known that pain is a subjective feeling, very differently emotionally colored in different people. The intensity, character, assessment of it depend on subjective perception and still do not lend themselves to any logical mathematical registration, at least in humans. If, for one reason or another, a person wants to hide the pain or, conversely, exaggerate it, he can always mislead the doctor and thereby distort the treatment. There are no direct, accurate indicators of pain sensation. Devices that assess the strength and nature of pain have not yet been invented. We judge it, as a rule, by indirect phenomena - by dilated pupils, increased blood pressure, rapid breathing, paleness or redness of the face, biting of the lips, twitching of muscles. But basically, when we study pain in a person, we are guided by his subjective assessments.
When a patient has pain, the main goal of nursing care is to eliminate the causes of pain and to alleviate the suffering of the patient. It should be borne in mind that eliminating chronic pain is a daunting task and often the goal may be only to help the person overcome pain.
Pain and the desire to reduce it are the main reasons people seek medical help. Many people understand that it is not always possible to completely relieve pain. In addition to the nurse's prescription drug therapy, there are other methods of pain relief within her competence. Distraction, changing body position, applying cold or heat, teaching the patient various relaxation techniques, rubbing or lightly stroking the painful area can also reduce pain.
Disciplines providing | MDK.04.01 "Theory and Practice of Nursing" Topic: "Nursing process in pain» | Disciplines provided |
OGSE.00 General humanitarian and socio-economic cycle OGSE.01. Foundations of philosophy | PM 01. Carrying out preventive measures MDK.01.01. A healthy person and his environment MDK.01.02. The basics of prevention MDK.01.03. Nursing in the system of primary health care to the population |
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OP.00 General professional disciplines OP.01. Basics of Latin with Medical Terminology OP.02. Human anatomy and physiology OP.03. Fundamentals of pathology OP.05. Hygiene and human ecology OP.06. Fundamentals of Microbiology and Immunology OP 09. Psychology OP 11. Life safety |
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PM 02. Participation in medical- diagnostic and rehabilitation processes MDK.02.01. Nursing care for various diseases and conditions MDK.02.02. Basics of rehabilitation |
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PM 03. Provision of first-aid medical care in case of emergency and extreme conditions MDK.03.01. Fundamentals of resuscitation MDK.03.02. Emergency Medicine |
Educational and methodological support of the topic "Nursing process in pain"
Handouts (per student):
- Educational literature "Theoretical foundations of nursing" S.А. Mukhina, I.I. Tarnovskaya, 2010
- Toolkit
- Documentation for the implementation of the nursing process
- Test tasks
- Situational tasks
Teaching and visual aids
- Multimedia presentation "Nursing Process"
- Before starting work, familiarize yourself with the relevance of this topic and the objectives of the lesson. You must learn to:
- conduct an initial assessment of the patient's needs;
- identify possible patient problems;
- determine the possible goals of nursing care;
- plan nursing care;
- carry out nursing interventions;
- evaluate the results of nursing care;
- document all stages of the nursing process
2. Specify what is covered on this topic in the educational literature "Theoretical Foundations of Nursing" S.А. Mukhina, I.I. Tarnovskaya, and which section you need to learn.
3. To check the initial level of knowledge on the topic, answer the questions of test assignments (using lecture material and educational literature on this topic as an auxiliary material).
4. To master a new topic, you are invited to use the educational literature "Theoretical foundations of nursing" S.А. Mukhina, I.I. Tarnovskaya, 2010, pp. 274-292 and this methodological manual "Nursing process in pain"
5. Prepare everything you need for work:
methodological guide forthe topic "Nursing process in pain";
documentation for the implementation of the nursing process and read the tasks TO BE ABLE.
6. Familiarize yourself with the information block of the methodological manual and the material in the educational literature.
7. To master this topic, solve situational tasks, fill out the documentation for situational tasks, compare with the standard answers.
8. To consolidate the data obtained, answer the questions of the test tasks, compare with the standards of the answers.
9. Summarize the work done.
Analgesia | No pain |
Antidepressants | Medicines that improve mood and overall mental health |
Irradiation | Spread of pain |
Localization | |
Myositis | Skeletal muscle inflammation |
Neuritis | Inflammation of the peripheral nerves |
Paraplegia | Paralysis of both limbs (upper or lower) |
Placebo | Pharmacological neutral compound used in medicine to simulate drug therapy |
Tranquilizers | Medicines that reduce the state of anxiety, fear, anxiety. |
Algology | The Science of Pain |
Pain threshold | The first, very weak feeling of pain from physical impact |
Pain tolerance | The strongest painful effect that a person can withstand |
Pain tolerance interval | Interval between pain tolerance and pain tolerance interval |
Algogens |
Unpleasant sensory and emotional experience associated with true or possible tissue damage, as well as a description of such damage
Pain, a "marker" of ill-being in the body, "informs" about the damaging factors. This is a signal to activate the body's defenses. And as soon as this signal arrives, two components of pain appear:
Motor: avoidance reflex (withdrawal of the hand, search for a forced position, decrease in motor activity).
Vegetative: increased heart rate and blood pressure, increased respiratory rate, dilated pupils, etc.
Aspects of pain
Physical - pain can be one of the symptoms of a disease, a complication of one disease, as well as a side effect of the treatment. The pain can lead to the development of insomnia and chronic fatigue.
Psychological -pain can be the cause of the patient's anger, frustration with doctors and as a result of treatment. Pain can lead to despair and isolation, feelings helplessness. Constant fear of pain can lead to feelings of anxiety. A person feels abandoned and unnecessary if friends stop visiting him, fearing to disturb him.
Social - a person who is constantly in pain can no longer do his usual work. Due to independence from others, a person loses confidence in himself and feels his own uselessness. All this leads to a decrease in self-esteem and quality of life.
Spiritual - frequent and constant pain, especially in cancer patients, can cause fear of death and fear of the very process of dying. A person may feel guilty towards others for the excitement they cause. He is losing hope for the future.
Physiology of pain
Pain signals are transmitted by the nervous system in the same way as information about touch, pressure or heat.
Pain receptors – we call the nerve endings, when excited, there is pain.
Pain receptors in humans are
- in the skin,
- in the connective tissue membranes of muscles,
- in the internal organs and in the periosteum.
- pain receptors are also found in the cornea of the eye, which reacts sharply to any foreign particle.
Pain components
- Sensory component
When hands are immersed in water with a temperature above 45 ° C, they are excitedreceptors in the skin.
Their impulses convey information about
- the location of the hot stimulus,
- at the beginning and end (as soon as the hand is taken out of the water) his actions,
- about its intensity, depending on the temperature of the water.
- Affective component
Sensory sensation can cause pleasure or displeasure, depending on the initial conditions and other circumstances. This is true for almost all sensory modalities - sight, hearing, smell, or touch. Pain is an exception. The affects or emotions it evokes are almost exclusively unpleasant; it spoils our well-being, interferes with life.
Immersion of the hand in hot water causes not only pain, but also the expansion of blood vessels in the skin, increases blood flow in it, which is noticeable by its redness. Conversely, immersion in ice water constricts blood vessels and reduces blood flow.
Usually, all the components of pain occur together, albeit to varying degrees. However, their central pathways are completely separated in places, so pain components, in principle, may well arise in isolation from each other. For example, a sleeping person pulls his hand away from a painful stimulus without even consciously feeling pain.
Pain sensations increase:
- stress;
- constant mental focus on pain;
- fatigue.
Pain signals block:
- physical exercises;
- when using warm and cold compresses;
- after massage;
- as a result of physiotherapy;
- if you are in a good mood;
- if you are relaxed.
Types of pain
- Physical
- Primary - fast, stabbing, sharp,for example, a needle prick into the skin
- precisely localized,
- quickly disappears after removal of the stimulus,
- does not cause an emotional reaction;
- Secondary - slow, unbearable, burning
- appears 0.5-1 s after the sensation of primary pain,
- has no clear localization,
- some time remains after removal of the stimulus,
- accompanied by changes in the functions of the cardiovascular and respiratory systems,
- can affect the character of a person, her way of thinking
- Psychogenic
Pain is not what a person feels physically, but also an emotional experience. The perception of pain can change depending on what value a person gives to it, on his mood and morale.
The psychogenic type of pain is associated with the emotional state of the individual, the surrounding situation, traditions. Has an indefinite beginning, occurs without an obvious reason. The nature may be unclear. There is often a discrepancy between the severity of pain described by the patient and his behavior. May not be observed at night. The place of pain is poorly defined, it can change depending on the mood. It is removed by the action of antidepressant drugs and methods that reduce emotional stress.
Classification of pain according to duration
Signs | Sharp pain | Chronic pain |
Duration of pain | Relatively short | More than 6 months You can set the moment of onset of pain |
Localization | Usually has a clear localization | Localized to a lesser step |
Start | Sudden | Starts out imperceptibly |
Objective | Increased heart rate | Absent |
Increased blood pressure |
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Increased NPV |
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Pale damp skin |
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Muscle tension in the area of pain |
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Facial expression |
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Subjective | Decreased appetite Nausea Anxiety Irritability Insomnia | Anxiety Depression Irritability Helplessness Fatigue Impaired ability to carry out daily activities Lifestyle change |
Likewise, pain is distinguished
- Surface - often appears when exposed to high or low temperatures, cauterizing poisons, as well as mechanical damage.
- Deep - usually localized to joints and muscles, and the person describes it as prolonged dull pain or excruciating, tormenting.
- Pain in internal organs – often associated with a specific organ.
- Neuralgia - pain that occurs when the peripheral nervous system is damaged.
- Irradiating pain– for example, pain in the left arm or shoulder with angina pectoris or myocardial infarction.
- Phantom pain amputated pain, often felt like a tingling sensation. This pain can last for months, but then it goes away.
- Psychogenic pain – pain without physical stimuli. For a person experiencing such pain, it is real, not imaginary.
Pain relief methods
Physical | Psychological | Pharmacological |
Change in body position | Communication, touch | Non-narcotic analgesics |
Application of heat and cold | Distraction or diversion of attention | Narcotic analgesics |
Massage | Music therapy | Tranquilizers |
Acupuncture | Relaxation and meditation (auto-training) | Psychotropic |
Electrostimulation | Hypnosis | Local anesthetics |
- Initial assessment
It is difficult to give an initial assessment of pain, since pain is a subjective sensation that includes neurological, physiological, behavioral and emotional aspects. In the initial, ongoing and final assessment, conducted with the participation of the patient, the patient's subjective feelings should be taken as the starting point. Describing pain by a person and observing his reaction to it are the main methods for assessing the condition of a person experiencing pain.
Methods
The description of pain by the person himself | Localization of pain The nature of the pain |
Investigating the Possible Cause of Pain | Time Possible cause of pain onset Conditions of disappearance Duration |
Observing a person's response to pain | External pain response may be absent |
The intensity of pain should be assessed based on the patient's experience of pain. |
Pain response
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Facial expression |
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Body movements |
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Limiting social interactions |
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Determination of pain intensity
Objective pain assessment is the main problem algology.
In clinical practice, various interview options are used to assess pain.
The simplest and most common algorithmic method is a visual analogue scale, on which the patient fixes a position corresponding to the intensity of pain in the range from the complete absence of pain to the maximum imaginary level of its severity.
For examples of rulers with a scale for determining the intensity of pain, see Appendix 1.
- Identifying patient problems
It is very important that the nurse draws conclusions after the initial assessment, not only based on the results of the examination of the patient and his behavior, but also on the basis of the description of pain and its assessment by the patient himself: pain is what the patient says about it, not what they think other
- Setting goals and planning care
When a patient has pain, the main goal of nursing care is to eliminate the causes of pain and to alleviate the suffering of the patient. It should be borne in mind that eliminating chronic pain is a difficult task and often the goal may be only to help a person overcome pain.
Problem | Purpose of nursing care |
Inability (unwillingness) to carry out personal hygiene on a daily basis due to pain. Difficulty doing personal hygiene due to pain | The patient performs daily personal hygiene with the help of a nurse (relatives, independently) |
Decreased appetite (weight loss) due to pain |
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Lowered self-esteem due to a change in appearance due to pain |
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Sleep disturbance due to night pain |
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Decreased motor activity |
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Difficulty in carrying out physiological functions due to pain |
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Difficulty exercising the ability to dress (undress) |
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Communication difficulties due to pain |
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Inability to work and rest as the patient is accustomed to |
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Loss of independence due to decreased physical activity due to pain (this may include problems such as, difficulties with the implementation of personal hygiene, physiological functions, the ability to dress and undress, |
- Nursing care
To achieve these goals and assess the effectiveness of pain relief, the nurse must accurately imagine the entire cycle of pain-related phenomena.
The cycle of pain-related events
Increased pain lack of knowledge (fear, anxiety, anger, sadness,
Depression, apathy)
Prophylaxis information (understanding, empathy, compassion, distraction)
Decrease elimination of symptoms (improvement of mood, sleep, rest, relaxation, warmth, sedation, analgesia).
- If you have any problems while taking the medicine, see your doctor. The doctor may change the dosage and timing of the drug, or the drug itself, which is better for your case.
5. Evaluation of the result
The goal is achieved if the pain is reduced and the patient becomes less dependent on daily needs.
Exercise 1
Solve a situational problem
By checking and correcting the baseline
knowledge on the topic "Nursing process in pain"
Patient P.I. Sidorov is undergoing treatment in the therapeutic department. 76 years old.
Initial assessment of the patient's condition:
NPV - 26 per minute, heart rate - 106 per minute, blood pressure 160 \ 90 mm Hg, T 0 bodies - 36, 6 0 ... Height 186cm, weight 80kg.
The skin is of normal moisture, warm to the touch. Cyanosis of the lips. The patient is worried about pain in the left side of the chest, which increases with deep breathing, a strong cough with a viscous, yellow-green sputum. The patient does not know the technique of effective coughing and the position in which the pain in the left side is reduced.
Exercise:
- Complete the Initial Assessment Sheet in the Requirement for Normal Breathing section. Justify the answer.
- Create a nursing care plan for unfulfilled movement needs using the chart below. Justify the answer.
Patient Initial Assessment Sheet
2. Nursing care plan
Assignment 2
Test tasks on the topic "Nursing process in pain"
Add a sentence
- Pain is …………
- Localization is ……… ..
- Analgesia is ……………
- Algology is ………… ..
- Algogens are ……………
- Aspects of pain
- ……………………
- …………………..
- …………………..
- ………………….
- Pain receptors are located ……….
- Pain components ……………….
- Classification of pain by duration …….
- The pain response can be …………….
Assignment 3
Test task to consolidate knowledge on the topic: "Nursing process in pain"
Choose one correct answer
- Method of organization and practical implementation by a nurse of her duty to serve the patient
- Diagnosis of diseases
- The healing process
- Nursing process
- Disease prevention
- The second stage of the nursing process
- Nursing examination
- Planning the scope of nursing interventions
- Setting goals for nursing care
- Evaluation of the nursing process allows you to determine
- Rapid nursing care
- Duration of illness
- Nursing quality
- Causes of the disease
- Subjective method of nursing examination
- Patient questioning
- Definition of edema
- Blood pressure measurement
- Patient examination
- The third stage of the nursing process
- Patient examination
- Identifying patient problems
- Drawing up a care plan
- Purpose of the first phase of the nursing process
- Patient examination
- Drawing up a care plan
- Performing nursing interventions
- Nursing process - a method of organizing care
- Urgent
- The medical
- Nursing
- Clinical
- Patient assessment - a step in the nursing process
- First
- Second
- Third
- Fourth
- The nurse determines the needs of the patient during the period
- Patient examinations
- Setting care goals
- Determining the scope of nursing interventions
- Nursing plan implementation
- Conversation with the patient - examination method
- Objective
- Subjective
- Additional
- Clinical
- Measurement of height and determination of body weight - examination method
- Subjective
- Objective
- Additional
- Clinical
- Study of NPV, pulse, blood pressure - a method of examining a patient
- Additional
- Objective
- Clinical
- Subjective
- Physiological items assess the patient's condition
- Emotional
- Psychological
- Social
- Physical
- Anthropometric research includes the definition
- Body mass
- Body temperature
- Pulse
- HELL
- Mobility - the patient's condition
- Mental
- Physical
- Social
- Spiritual
- Increased blood pressure
- Hypotension
- Hypertension
- Tachycardia
- Bradycardia
- Tachypnea
- Reduced heart rate
- Reducing breathing
- Increased heart rate
- Increased breathing
- Increased heart rate
- Tachypnea
- Bradypnea
- Tachycardia
- Bradycardia
- Patient's priority physiological problem
- Pain
- Anxiety
- Weakness
- Lack of appetite
- Incomplete patient information is a problem
- Valid
- Intermediate
- Potential
- Temporary
- Unsatisfied human problems
- A wish
- Capabilities
- Possibilities
- Needs
- Documenting the first step of the nursing process is a prerequisite
- Continuous
- Optional
- Mandatory
- Temporary
- Documentation of the stages of the nursing process is carried out in
- Patient observation medical record
- Outpatient card
- Destination list
- Patient's nursing history
- Physiological problem of the patient
- Sleep disturbance
- Inability to attend church
- Fear of job loss
- Material difficulties
- The purpose of the nursing process
- Collecting patient information
- Ensuring a decent quality of life
- Establishing the nature of nursing interventions
- Assessment of the quality of nursing care
The standard of the answer to the problem according to the initial level of knowledge
on the topic "Nursing process in pain"
1. The need for normal breathing
2. Care plan
Problem | S / V goals | Nursing intervention | Multiplicity appraisals | final grade |
The patient does not know the position of relieving pain in the left side of the chest | The patient takes a position that relieves pain (position on the sore side) | 1. Train the patient to take a position that relieves pain 2. Help the patient to take the required position 3. Train relatives to help the patient take polo feeling that relieves pain. | 5 times a day | After 2 days the patient is able to adopt a position that relieves pain |
The patient does not know effective cough technique | The patient uses effective cough technique | 1. Explain to the patient why it is necessary to use the effective cough technique. 2. Teach the patient the technique of effective coughing. 3. Help the patient use the effective cough technique | 4-6 times a | The patient uses the effective cough technique after 2 days |
Standards of answers to test tasks
on the topic "Nursing process in pain"
- An unpleasant sensory and emotional experience associated with actual or possible tissue damage and a description of such damage
- Place of development of the pathological process
- No pain
- The Science of Pain
- Special substances that stimulate the activity of painful nerve endings
- Physical, mental, social, spiritual
- In the skin, connective membranes of muscles, internal organs and periosteum, the cornea of the eye
- Sensory, motor, affective, vegetative
- Acute and chronic
- Voice, facial expression, body movement
Evaluation Criteria for Test Items
on the topic "Nursing process in pain"
"5" - 90% correct answers (1 to 2 errors are acceptable)
"4" - 80% correct answers (3 to 4 errors are acceptable)
"3" - 70% correct answers (5 to 6 errors are acceptable)
"2" - less than 70% of correct answers
Standards of answers to test tasks to consolidate knowledge
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