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Evaluation Scales as a Part of the Nursing Documentation
HANDREJCHOVÁ, Ivana
The bachelors thesis deals "Evaluation Scales as a Part of Nursing Documentation". The bachelors thesis consists of two parts. The theory part dealt with nursery documentation and evaluation scales. The objective of the thesis was to present portions of nursery documentation that are based on legislation and the use of nursing documentation in the course of the nursing process. It described the areas of assessment of patient's medical condition by a nurse allowing the use of more evaluating scales. In the practical part of the thesis three objectives were set. The first objective was to map out evaluation scales used by nurses in selected health care facilities. The second objective involved mapping out understanding of nurses of and in using evaluation scales. The third objective was to establish whether nurses can actively participate in selecting of evaluation scales in their wards. Three assumptions were then set up. The first assumption was as follows: "The use of evaluation scales varies according to the type of the health care facility". The second assumption read: "Nurses are informed on the possibilities of using evaluation scales". The third assumption read: "Nurses can participate in active selection of evaluation scales". A quantitative method of anonymous questionnaire was employed to establish the factual state. A single questionnaire type was used for all nurses. The questionnaire involved 33 questions and 12 subquestions that were closed and semi-closed for addition of a short answer. Opening questions of the questionnaire were of identification nature. Subsequent questions dealt with different evaluation areas, the use of evaluation scales and perception of evaluation scales by nurses. The file of questioned persons consisted of nurses serving in the České Budějovice a.s. and the Nemocnice Písek a.s. hospitals. In total 168 questionnaires were distributed. 84 of them to nurses of the České Budějovice a.s. hospital and 84 questionnaires to nurses of the Nemocnice Písek a.s. hospital. Clearly set diagrams were processed based on nurses' answers. Discussion results were compared with specialized literature. The final part of the thesis contains summary results and assumptions of the thesis author are confirmed or rebutted herein. The first assumption: "The use of evaluation scales varies according to the type of the health care facility" has been confirmed. The second assumption: "Nurses are informed on the possibilities of using evaluation scales" has been confirmed. The third assumption: "Nurses can participate in active selection of evaluation scales" has been confirmed.
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The application of the King´s model in the care of client to the orthopedic department
KREMSOVÁ, Alžběta
My thesis deals with the possibility of applying King?s model to client care at an orthopaedic department. King?s model is focused on interaction between a nurse and a patient. Achievement of harmony in interaction between a nurse and a patient/client creates better conditions for attainment of the care goals and thus saturation of his/her needs. In combination with Gordon?s model better satisfaction of needs and thus improvement of the care at the orthopaedic department would be achieved.
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Problems of Nursing the Patients Self-intoxicated in Suicidal Intention.
DRÁBKOVÁ, Iveta
Suicide as an individual event as well as a social phenomenon attracts great interest and attention in various spheres, both in the immediate environment of the self-murderer and in broader public. The definition of suicide differs according to authors and changes in the course of historical development. Most definitions are identical in two essential aspects of suicidal behavior. These are a voluntary individual's intention to terminate his life and a purposeful behaviour leading to death. Suicide is the conscious and intentional killing of oneself. About 95% of suicidal attempts are just acute intoxications by any amount or kind of a poisonous substance. Acute intoxication belongs to a group of serious conditions threatening human health and life. Acute poisoning is one of the frequent admission diagnoses in the Departments of anesthesiology and resuscitation and Intensive care units. 80% of poisonings are caused by drugs. Damage to the organism by ingesting a poisonous substance is the more significant the longer is the interval between the exposure to noxae and the professional medical assistance provision. For the future fate of the patient the medical equipment and the competence of health professionals who provide intensive care for these patients is crucial. After stabilization of all physiological functions, balancing inner environment of the patient and after the time that may have led to late complications of intoxication, the following phase of treatment is provided by psychological and psychiatric interventions. Determination of suicidal risk among the most common challenge in urgent psychiatry is suicide risk assessment. The aim is to prevent further suicide attempts. The objective of the thesis was to determine, with regard to the competence of nurses, the predominant character of patients´ experience after intoxication, and also the reasons for aggressive behavior of intoxicated patients towards the nursing staff. The third objective was to establish a standard of nursing care of intoxicated patients. The research was designed as explorative with the goal to map the nursing process in intoxicated patients and to provide information for the establishment of the standard of nursing care, which should include both somatic and psychological aspects. Quantitative and qualitative methods were combined. The outcomes of the thesis should lead to detection of the most frequent problems in nursing care for patients with intentional intoxication with suicidal tendency and the establishment of nursing standards to help improve the care of these patients.
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Analysis and inovation selected nursing documentation used in the workplace intenzive medicine
KŘÍŽOVÁ, Radmila
The thesis topic: ?Analysis and Innovations of Selected Nursing Documentation Used in Intensive Care? was chosen deliberately for its topicality. Documentation is an important and integral part of treatment of patients. It is very important that nursing documentation suit nurses who work with it. Data should be clear and their recording easy and convenient for nurses. Duly managed nursing documentation should be beneficial for physicians as well. For the research, the anaesthetic resuscitation department in Jihlava was chosen. The thesis contained six defined objectives that have been met and resulting 6 research questions. Qualitative research was carried out in 3 stages. One research group consisted of nurses at the anaesthetic resuscitation department in Jihlava, the other research group consisted of doctors at the anaesthetic resuscitation department in Jihlava. In the first stage, an analysis of nursing documentation used at the anaesthetic resuscitation department in Jihlava was carried out and, subsequently, interviews with the nurses and doctors from this department were conducted. In the second phase, innovations of nursing documentation were made and the documentation was put into practice. The final stage of the thesis consisted of interviews with the same questions for the doctors and nurses at the anaesthetic resuscitation department in Jihlava, in which opinions of the nurses and doctors on the innovated documentation and its application in practice were surveyed. The objective was to analyze the existing nursing documentation, to innovate it on the basis of the interview results, to implement it, and then to find out whether it could be used in practice. Based on the interviews conducted, we found out that nurses do not like the nursing diagnoses and also record sheets, which are common for doctors and nurses, used their department. Based on these results, innovation of the nursing diagnoses was made and, at the same time, the department made an innovation of the recording sheet, and medical and nursing documentation was separated. After the documentation was introduced into practice, we interviewed the nurses and doctors again to find out whether the innovated documentation was better and whether it could be improved more. We found out that the documentation was better, more suitable for the respondents. The innovated documentation can be used in practice and is currently so at the anaesthetic resuscitation department in Jihlava.
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Formation of Nursing Documentation and its Usage in the Home for Seniors Chýnov
CHAMROVÁ, Anna
Nursing documentation is becoming an important part of the medical documentation and it is an integral part of the nursing process in the homes for seniors too. The theoretical part of the Bachelor thesis ``Formation of Nursing Documentation and its Usage in the Home for Seniors Chýnov{\crqq} contains chapters concerning the nursing process and nursing documentation. Further this part deals with the characteristics of the Home for Seniors Chýnov and with the specific problems and needs of geriatric clients in particular the clients suffering from Alzheimer dementia. The target of the work is to make nursing documentation in the Home for Seniors Chýnov, to apply it in this establishment and to find out whether the availability of this documentation influences the holistic attitude of nurses to the client. The first stage of the research part involved formation of the new documentation and its application in the Home for Seniors. The respondents had an opportunity to work with the documentation in the months of January and February 2010. In the second part we tried to survey opinions of the respondents of the made documentation. Four research questions were preceding the research. Research question number 1: Shall the nurses working in the Home for Seniors Chýnov accept the newly made documentation as a part of the medical documentation? Research question number 2: Shall the nurses working in the Home for Seniors Chýnov refer to time consuming work with the documentation? Research question number 3: Has the new documentation influenced communication among the members of the nursing staff? Research question number 4: Shall the newly made documentation contribute to the change of the nurses´ opinion of the patients from the holistic philosophy point of view? To fulfil the set aims there was carried out the qualitative research using the method of questioning and semi-standardized interview. The research set consisted of 7 respondents (general nurses) working in this establishment. Considering the research results we suppose that the work target has been fulfilled. The research has proved that the newly made documentation has improved communication among the members of the nursing team and the nurses have accepted it as a part of the medical documentation. The aim of the work was making a quality nursing documentation which should be simple, not time consuming and which should be focused on specific needs of the clients of the Home for Seniors Chýnov. The thesis has practical contribution.
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The Application of the Virginia Henderson{\crq}s Model in Retirement Home Nursing Care.
KADEŘÁBKOVÁ, Věra
The Application of the Virginia Henderson{\crq}s Model in Retirement Home Nursing Care. Basic unit of the V. Henderson{\crq}s model is the clients{\crq} independence when satisfying their needs. The client is seen as an individual with the needs of assistance when trying to reach health, independence, and peaceful death. The lack of strength, will and knowledge are seen as the source of troubles. The needs the client is not able to satisfy and is in need of assistance are by V. Henderson called as the focus point intervention. The nurse assists to substitute, complete, support or increase the patient{\crq}s strength, will and knowledge. The outcome is the unaided performance in satisfying personal needs or peaceful death. The information about the needs is not documented in the uniform way and that is why every single ward and institution creates its own documentation system, according to its own specifics. The nursing documentation is always inseparable part of the nursing process. This model is determined by its specifics to be used appropriately in elderly people. The goal of this work was to find out all possibilities in using the Virginia Henderson{\crq}s model when caring of clients in the retirement home. There were placed three main questions of the research: 1.To what extents are satisfied the needs of client in the house for elderly people when using nursing documentation compiled according to V. Henderson? 2. Is there any influence of using V. Henderson{\crq}s model of nursing documentation on nursing practice in the retirement home? To what extent are nurses comfortable with the V. Henderson{\crq}s nursing documentation system? The collecting of data was done by the qualitative research investigation, the technique of the direct observation of nurses{\crq} caretaking of the clients, and by detailed interview with the nurses. The research had been done at Retirement Home at Strakonice from April to June 2009. There was created nursing documentation according to V. Henderson{\crq}s system. This documentation was filled out by a nurse and client and followed by searching for the needs of the client and their satisfaction. The nursing planned out specific care of a particular client using nursing process after filling out particular documentation. There has been led direct observation of caretaking provided under new nursing documentation. To assess the care, there was developed the point scale for evaluation of the client needs satisfaction (1-Satisfied, 2-Rather Satisfied, 3-Rather Unsatisfied,4-Unsatisfied). As a next we have been evaluating client{\crq}s level of strength, will and knowledge to be able to satisfy his/her needs (he/she is independent, partly independent, and dependent). The observation outcomes demonstrated that nurses were able to satisfy all of the 14 clients{\crq} needs in most. There were done case reports out of the observations and the results were processed into comprehensible charts. The nurses had been working with the nursery documentation for months followed by detailed interview aimed to inspect the usage of this documentation in nursing of elderly people. All of the five nurses agreed on the applicability of the documentation in nursing practice and that was why the documentation was modified under nurses{\crq} notes and has been applied in practice since. The research goal was accomplished. The nursing documentation has always been integral part of nurse{\crq}s work.It provides all needed information concerning the patient. It can be considered as the prove of ``lege artis{\crq}q practice of the work done. The documentation also serves as the record which is being used for health insurance billing.
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Comprehensiveness and completeness of managing of nursing documentation in selected medical institution
ZÁMOSTNÁ, Barbora
This bachelor thesis deals with the topic ``Complexity and completeness of keeping nursing care documentation in a selected medical facility``. The thesis is drafted in the theoretical part and empirical part. The objective of the empirical part of the investigation was to survey the complexity and completeness of keeping nursing care documentation in a selected medical facility. In accordance with the objective, we set two hypotheses. H1: Nurses keep nursing care documentation in accordance with the applicable standard. A H2: Nurses in surgery units keep nursing care documentation more complexly than nurses in internal departments. To collect data we chose the quantitative method of research by means of nursing care audit. The research sample consisted of 60 pieces of nursing care documentation, 30 pieces of documentation in a surgery unit and 30 pieces of documentation in the internal department of the Tábor Hospital, a.s. The overall success rate in the audit ``Complexity of keeping nursing care documentation{\crqq} was 99.73 per cent in the internal department and 91.12 per cent in the surgery department. At the same time, no audit index results have dropped below 76 per cent in the entire set (60 pieces of documentation), and below 53 per cent in partial sets (30 pieces of documentation). H1 hypothesis: Nurses keep nursing care documentation in accordance with the applicable standard, has been, on the grounds of the results obtained, confirmed. The overall success rate of the audit of the nursing care documentation in the internal department was almost by 8.5 per cent higher than that in the surgery department. For that reason, it is possible to make the conclusion that the H2 hypothesis: Nurses in surgery units keep nursing care documentation more complexly than nurses in internal departments, has not been confirmed. In the final discussion, results from the conducted audit in the two departments were summed up and, subsequently compared with literature. Practical use was set in the final part. The results of the bachelor thesis were given at the disposal of the staff nurse of the Tábor Hospital, a.s., to conduct improvement in keeping documentation or to conduct subsequent audits. Last but not least, a local standard for keeping nursing care documentation as the basis for drawing up a new standard in individual departments of the team of nursing care, was drafted and subsequently submitted.
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Realization of Nursing Care Concept in Practice
BALDOVÁ, Martina
The main objective of the thesis was ascertaining of realization of the Nursing Care Concept issued by the Ministry of Health in 2004, in Czech hospitals. To achieve results a quantitative research method was used. While collecting data we used a questioning method, by means of questionnaires. The questionnaires were intended for staff nurses/deputies of nursing care in Czech hospitals. As a research sample we chose hospitals in the Czech Republic which provide acute ward (bed) care. The found out data should clarify what is the actual status of realization of the Nursing Care Concept in Czech hospitals.
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The use of the nursing model by V. Henderson in care of a child client
ZEUNEROVÁ, Jana
Contemporary nursing care of children is based on the holistic approach aimed at the satisfaction of needs. Nurses in the majority of health facilities use documentation developed by M. Gordon. The nursing model by Virginia Henderson, however, is actually much better suited to the identification and subsequent satisfaction of children's needs. This model belongs to the category of models of needs and of humanistic models. A child's needs are divided into 14 basic domains in this model. The present bachelor's thesis describes a study of the use of nursing documentation based on Henderson's nursing model at the Department of Babies, University Hospital in Plzeň. In Part 1, the quasi-experimental method {--} observation method was applied to data processing. The research group included in-patient children at the Department of Babies. Part 2 of the research was quantitative, based on answers to questions asked by means of a questionnaire. Here the research group included nurses working at the Department of Babies, University Hospital in Plzeň.
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The influence of nursing documentation audit on nursing care quality
MACHÁČKOVÁ, Eva
Abstrakt The keeping of nursing documentation is an inseparable part of the work of a nurse. It is an instrument of professional practice, which is intended to support the process of care. The quality of the keeping of the nursing documentation is a reflection of the level of professional practice. The nursing documentation is an invaluable manner of supporting communication within the framework of the health care team and between the health workers and their patients/clients. Well kept nursing documentation is thus the product of good teamwork and at the same time an important instrument for increasing the quality of care. An audit is one of the parts of the management process and its final aim is to incease the quality of the provided care. An audit can play an important role during the delivery of the quality of the provided care and this is also true for the process of the keeping of the nursing documentation. During an audit of the kept documentation areas are identified where it is intended to ensure the improvement and education of the staff. The theoretical part the work also includes chapters related to the given problems that is the nursing aim, the nursing process, the nursing documentation, the quality of nursing care and the nursing audit. In the research part I deal with the influence of the audit of the nursing documentation on the quality of the provided nursing care. The aim of my research is to ascertain the influence of the standard of the nursing documentation on the quality of nursing care and to ascertain whether the results of the audit of the nursing documentation help the nurses in the wards to improve the quality of the provided nursing care. During the research my first hypothesis that the quality of the nursing care is increased by the carrying out of a standard ``Unified keeping of nursing documentation`` was confirmed and 26 of the questionned nurses (57%) agreed with it. The second hypothesis, that the quality of the nursing care is increased by the introduction of an audit of the nursing documentation into practice, was not confirmed. Only 18 of the interviewed nurses (39%) think that the introduced audit of the nursing documentation into practice is an increase in the quality of the nursing care. In order to obtain the required data to accomplish the aims and answer the hypothesis of quantitative research I used a method of auditing and an enquiry method using questionnaires. The research sample made up 50 (100%) of the examination documentation from five selected wards of Pelhřimov Hospital. The body of research in the case of the questionnaires was made by the nurses, working in the wards, where the audit of the nursing documentation was carried out. In total 46 of the nurses (100%) from all the assigned clinics took part in the survey. The results of the research were placed at the disposal of the administration of Pelhřimov Hospital, as a pilot study for the creation of their own complex standard and audit of the nursing documentation.
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