Patient observation
The medical observation is the systematic observation and perception of physical symptoms, signs and mental state of a patient in professional care . It is one of the core competencies of nursing and is essential for effective nursing planning within the nursing process . It serves the timely detection of complications, the monitoring of the course of therapy and the recovery, as well as the consideration of the wishes and needs of the person being cared for. The documentation of the observation is also part of the nursing process, so that the observation is made available to other nursing staff, the doctors treated and other professional groups involved in the therapy.
parameter
Both physical and psychological changes are observed. Some of these are monitored with aids, others are part of the nurse's experience. These include:
- Posture and gait
- Facial expressions and facial expressions
- Voice and language
- psychological changes and abnormalities, cooperation and coping strategies
- State of consciousness
- odor
- sleep
- pain
- Skin and appendages
- Oral cavity
- Nutritional condition and weight, general condition, body length
- Excretions: urine, stool, sputum , sweat, vomit, wound exudates , menstruation and vaginal excretions
Depending on the subject, additional focal points can be set, e.g. B. the wound observation , blood sugar or observation of side effects of given drugs.
method
The observation of the patient can take place during every interaction with the patient (for example during personal hygiene ), it can be an accidental observation, during the nursing anamnesis it can take place or be planned (for example during monitoring in the intensive care unit ). The observation of the sick must be subject to fixed criteria; the observations should be evaluated objectively during the evaluation and should not contain any evaluation. A good relationship between patient and nurse, the planning of patient observation and a high level of professional competence of the nurse have positive effects. Prejudices, time pressure, stress and limitations of the sensory functions, however, have a negative effect on patient observation.
literature
- Christa Deltz: patient observation Springer, 1994 ISBN 978-3-642-79072-0
- C. Lanzendörfer, R. Lanzendörfer, H. Schardelmann, C. Subbe: Internal medicine: pathology, patient observation, special care Springer, 1998 ISBN 978-3-642-87097-2
Individual evidence
- ↑ Christa Deltz: Krankenbeobachtung Springer, 1994 ISBN 978-3-642-79072-0 pp. 2–12