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Specifics of nursing documentation in providing nursing care foreign patients
KUBIŠOVÁ, Pavla
Abstract This diploma work?s title is ?Special Characteristics of Nursing Care Documentation at Providing Foreign Patients with Nursing Care?. Nursing care documentation is very important, which statement represents general consent of all medical officers of health however the aforementioned nursing care documentation is rather complicated and disunited and uncoordinated. The greatest problem that appears here consists in needs being different taking into consideration culture, country, which the person (patient) comes from and the patient?s religion that the patient practices. Therefore it is important to bring order and consolidate all relevant pieces of information and think over nationwide use of this important data containing foreign patient characteristics. At present paying attention to this problem is worth not only noticing but also solving it because due to increasing migration to and within the Czech Republic territory it is expected that there will be a lot of different cultures as well as nationalities and medical personnel is expected high level of nursing care taking account of their needs. In the beginning there were set the following two goals: To ascertain whether the existing nursing documentation contains specific pieces of information necessary for providing nursing care for foreign patients and to determine whether it is necessary to make specific pieces information regarding foreign patients an integral part of nursing documentation. Three research questions were established at the same time then. The first research question focused on the fact whether the documentation having been used in hospitals was adapted to satisfy biological, psychical, social and spiritual needs of foreign patients. Thanks to the research question number two we made effort to ascertain and identify whether the documentation applied and being used in hospitals covers also the specific documentation oriented to foreign patients. The third and last research question solved the problem whether it is necessary that specific pieces of information dealing with foreign patients should be an integral part of nursing documentation. Inquiry check and examination were carried out by applying method of qualitative examination by means of non-standard interview and during the second part of interview data analysis was used. The research samples were represented by nurses working at hospital wards in the hospitals within South Bohemia Region, West Bohemia Region, Central Bohemia Region and North Moravia Region. Applying interview forms processed the pieces of information provided by nurses. The inquiry checks and examinations showed that the nursing documentation used in the hospital wards does not contain in sufficient scope the pieces of information oriented to the foreign patients and foreign clients which results in foreign patients and clients not satisfying biological, psychical, social and spiritual needs. It follows from this that nurses working at hospital wards do not have available and at their disposal the documentation related to the foreign clients and patients and dealing with the foreign clients? needs ? the existing nursing documentation is only one and it is applied and used for all hospital clients i.e. it is uniform. It is possible to make the conclusion that the first goal having been established has been met and the same hold good for the second one. In the connection and context with pieces of knowledge having been ascertained we should like to recommend that nurses working at hospital wards should have the possibility of getting familiar with multicultural nursing and it would be advisable and appropriate to provide nursing documentation oriented to foreign clients coming from foreign countries. It appears important from the point of view to satisfy the needs of these clients, which will bring nursing care new higher quality.
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The importance of Anamnesis within the Treatment of Children in Various Development Stages
KUBIŠOVÁ, Pavla
The Bachelor{\crq}s work deals with a theme on Importance of Anamnesis within the Treatment of Children in Various Development Stages. The treatment documentation, in our case referred to as treatment anamnesis, is an essential part in order to provide a relevant treatment care. First of all, a nurse or other healthcare professional has to learn more about a patient as well as to find out detailed information in order to formulate a diagnosis and to decide on the most suitable treatment plan provided. Individual procedures and the principles followed when obtaining the information are as well very essential. There were two aims and two investigative questions established. The first aim of the Bachelor{\crq}s work was to focus on different ways that vary in obtaining the treatment anamnesis concerning children in various development stages. The second aim of the work was to draft a treatment documentation used for obtaining the anamnesis concerning children in particular stages of development. The first investigative question raises query if there are any distinctions in obtaining data or information about children{\crq}s patients in particular life stages. The second investigative question focuses on methods used by nurses or healthcare professionals to collect a medical history about children{\crq}s patients in particular life stages. The investigation was executed by a qualitative method using non standardized encounters, data analyses and observations. Nurses working in the children{\crq}s ward in the hospital in Strakonice and Písek were the subject to the research. The investigation was carried out during two weeks. It was ascertained during the investigation that the nurses working in the particular children{\crq}s wards in the hospital selected proceed differently when obtaining anamnesis information about particular children{\crq}s stages of life. The investigative question results in hypothesis no. 1: `Nurses who carry out the task vary in used methods of obtaining the anamnesis data concerning children.{\crq} Hypothesis no. 3: `Supporting documents used for obtaining the anamnesis data concerning children{\crq}s patients are not equal in healthcare centres.{\crq} The second investigative question result in findings that anthropometric measurements are ascertained in all children of different life stages. Some nurses do not follow the standard methods and principles of the encounters and not all nurses use correct methods when obtaining the information. Three further hypotheses result from the second investigative question: Hypothesis no. 2: `When collecting the anamnesis data, nurses do not follow the rules of guiding the interview with a patient.{\crq} Hypothesis no. 4: When collecting the anamnesis data concerning children{\crq}s patients, nurses always ascertain their anthropometrical features according to individual stages of development. Thus shows that the first aim was fulfilled as well as the second aim assessed. Within the context of the actual findings, we would recommend to propose documentation for obtaining the anamnesis data aimed for children{\crq}s wards in hospitals which would have the same, equal layout, best within the whole Czech Republic. It would be important to make the supporting documents simple and clear to understand in order to make nurses{\crq} job easier. The documentation would consequently simplify the formulations of treatment diagnoses, thus would contribute to provision of high quality of treatment in order to meet the patient{\crq}s needs. At the same time, it would be suitable to arrange courses and seminars focused on the stated theme aimed for individual hospitals and healthcare centres in the Czech Republic and to solve relevant problems concerning anamnesis documentation on the spot.
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