QUY TRINH DIEU DUCiNG
MUC Tl£U
1. Neu ditqc dinh nghia - muc dich cua quy trinh dieu dtfdng.
2. Trinh bay dtfdc noi dung cac btfdc cua quy trinh dieu dtfdng.
3. Lap dtfdc bang ke hoach cham soc cho ngtfcfi benh.
1. DAI CLfdNG
- Quy trinh dieu diidng la mot loat cac hoat dong theo mot ke hoach da
dUdc dinh trtfdc, trtfc tiep hudng tdi mot ket qua cham soc rieng biet.
- Quy trinh dieu dudng la mot loat cac he thong va phUdng phap to chtic
cua ke hoach cham soc.
- Quy trinh dieu diidng diidc ting dung de:
+ Nhan biet tinh trang thtfc te v& nhting van de cham soc stic khoe cho
moi ca nhan.
+ Thiet lap nhting ke hoach dung v6i nhting kho khan cua ngtfdi benh va
dap ting cac nhu cau can thiet cho ngtfdi benh.
- Quy trinh dieu diiQng co 5 btfdc:
+ Nhan dinh
+ Chan doan
+ Lap ke hoach
95
2. NHAN DINH
2.1. Dinh nghia
- Dinh nghia: nhan dinh dieu dtfdng la mot qua trinh thu thap thong tin co
to chiic va he thong diidc sii dung de danh gia tinh trang siic khoe cua
moi ca nhan.
- Nhan dinh la sii thu ltfdm, danh gia, tham dinh, va ghi chep chinh xac
cac thong tin thich hdp vdi tinh trang benh hien tai cua ngtfdi benh.
- Nhan dinh dieu diidng la nen tang tren cd sd do xay dtfng cong tac ch&tn
soc cho ttfng ca nhan co chat ltfdng.
2.2. Noi dung nhan dinh
Noi dung nhan dinh phai bao gom: nhan dinh thiic the, tam than/cam
xuc, tinh trang kinh te-xa hoi, nhan djnh ve tinh than-v&n hoa va moi trtfdng.
Cac thong tin da thu nhan dtfdc ttf phan nhan dinh nen mo ta ngan gon, diy
du va khong nen dien giai.
- Nhan dinh thtfc the:
La stf nhan dinh thtfc te ve ho hap, tuan hoan, nhiet do, da, tinh trang
dinh dtfdng, bai tiet, dich, chat dien giai, van dong, nghe, nhin, mieng, ve sinh
noi chung, cac benh mac phai trtfdc kia, benh hien tai, cac yeu to nguy cd, xem
xet lai cac dau hieu va cac trieu chtfng cua benh.
- Nhan dinh ve tam than cam xuc:
La stf dap tfng bang ldi, tam tinh, hanh vi, chtfc nang tri thiic, ttf duy,
khoang thdi gian, stf chu y, tri nhd (lau hay k6m), lo sd, hieu biet ve benh t&t,
ngon ngtf, cii chi.
- Nhan dinh ve xa hoi / kinh te:
+ Trinh do van hoa, sii hieu biet xa h$i, nhiing anh htfdng van hoa ddi
vdi ngtfdi benh nhtf the nao?
+ Cd cau gia dinh, tinh trang lam viec, tinh trang tai chinh?
- Nhan dinh ve tinh than/ van hda:
La stf can nhac, xem xet dac biet ve moi quan he giuta tin ngtfdng ton giao
va trinh do van hda cua ngtfdi benh.
- Nhan dinh ve moi trtfdng:
Sv* nhan dinh ve dieu kien song, lam viec co anh htfdng den nguyen nhan
cua benh tat? co kha nang phong ngijfa dtfdc b fn h khong?
96
2.3. Phan loai th on g tin nh an din h
Thong tin thu thap dtfdc tti phan nhan dinh co the dtfdc chia thanh 2
loai: thong tin khach quan va thong tin chu quan.
- Thong tin khach quan.
+ Thong tin khach quan la loai thong tin ma ngtfdi khac co the nhan
thay dtfdc d ngtfdi benh.
+ Thong tin khach quan thu thap dtfdc qua viec kham thtfc the ngtfdi
benh vi du: nhiet do tang len, mach tang, tinh trang da, ltfdng ntfdc
tieu, han che cti dong. Day la cac dau hieu cua benh tat hoac stf thay
doi tinh trang cua ngtfdi benh.
- Thong tin chu quan.
Thong tin chu quan: la thong tin ngtfdi benh nhan thay dtfdc, ngtfdi khac
khong nhan thay dtfdc.
+ Nhting than phien cua ngtfdi benh ve dau, nhQng dieu cam nhan dtfdc
cua ngtfdi benh ve benh tat, nhtii g lo lang...do la nhiing dap ting chu
quan cua ngtfdi benh, no cung dong vai tro quan trong trong viec nhan
dinh dung ve mot van de cu the, vi du: mot ngtfdi benh keu dau tang
len sau 3 ngay hau ph lu muon chi ra co van de co the xay ra.
+ Khi mo ta thong tin chu quan can phai mo ta cu the, ro rang, chinh
xac. Ngtfdi b§nh keu dau: cln m6 ta ve ctfdng do, thdi gian, vi tri, va
nhting van de khac co lien quan tdi dau.
+ Trong trtfdng hdp can thiet co the trich dan nhting ldi noi cua ngtfdi
benh ma khong dtfdc dien giai nhting ldi noi do theo cach hieu chu
quan cua ngtfdi dieu dtfdng.
2.4. N guon th o n g tin
- Ngtfdi benh.
+ 6 hau het cac tinh huong, ngtfdi benh la nguon thong tin tot nhat.
+ Ngtfdi benh co the cung cap thong tin chinh xac nhat dtfa vao tinh
trang stic khoe cua ban than ho.
+ Chi stf dung thong tin tti nguon khac mang tinh chat chu quan neu
ngtfdi benh khong co kha nang nhan biet de tra ldi cac cau hoi: trtfdng
hdp ngtfdi benh bi lin Ion khong dinh htfdng dtfdc, khong co kha nang
de truyen dat cac thong tin can thiet.
- Gia dinh va nhting ngtidi than.
Gia dinh va nhting ngtidi than cua ngtfdi benh co the cung cap cac thong
tin ve nhting van de hien tai, cac thuoc da dung, tien sti di ting, benh mdi mac,
hoac cac benh mfic phai trtidc kia cua ngtidi benh.
- Nhan vien y te khac.
Bac si, nha vat ly tri lieu co the cho biet nhiing thong tin khach quan rat
thich hdp, can thiet va co Ich trong mot so trtfdng hdp.
- Ho sd ngiidi benh.
Ho sd ngtfdi benh khong nhQng cung cap nhQng thong tin ve hien tai vk
triidc kia, ma con giup xac minh nhQng thong tin do ngiidi benh cung cap va chi
ra cho chung ta thay hiidng dieu tri da stf dung co hieu qua hay khong.
2.5. Phtfdng ph ap th u thap th on g tin
2.5.1. Phong van (hoi benh, khai thac benh sii, tien sti benh) ban dau
- Phong van dac biet la phong van ban dau cua dieu dQdng vdi ngiidi benh
la yeu to rat quan trong trong viec thiet lap moi quan he trong dieu tri.
Trong qua trinh phong van ngiidi benh de thu thap thong tin, ngiidi dieu
dtfdng phai chu trong nhQng thong tin ma ngQdi benh dQa ra, v& phai giii
kin cho ho. SQ dam bao bi mat thong tin cho ngQdi benh se khuyen khich
ngiidi benh cung cap thong tin nhieu hdn cho can bo y te. Cang nhieu
thong tin cang co gia tri cho ngiidi dieu dQdng, bdi tren cd sd nhQng thong
tin do se giup cho viec diia ra chan doan dieu dQdng dQdc chinh xac.
- Phong van ban dau co y nghia tam quan trong:
+ Cho phep ngQdi benh / dieu dQdng vien thiet lap moi quan he.
+ Thu thap dQdc cac thong tin ve ngQdi benh.
+ Cho phep dieu diidng vien quan sat ngtfdi benh.
+ Cho phep ngtfdi benh dtfa ra cac cau hoi.
+ Giup ngtfdi dieu dtfdng xac dinh dtfdc ngtfdi benh co nhQng van de gi.
+ Dtfa ra cac thong tin dtfdc stf dung de lap KHCS dat yeu cau.
- Moi quan he tot giQa ngtfdi benh va dieu dtfdng co gia tri cao trong dieu
tri. Stf tac dong qua lai cua ho dtfdc dtfa tren cd sd niem tin ma trong do
ngtfdi dieu dtfdng the hien kha nang nghe nghiep cua minh trong cham
soc va bieu lo stf cam thong doi vdi hoan canh cua ngtfdi benh. Ngtfdi dieu
dtfdng can phai lam cho ngtfdi benh hieu ro trach nhiem cua minh trong
viec lap ke hoach cham soc ngtfdi benh.
2.5.2. Kham thiic the
- Tham kham ngtfdi benh thtfdng dtfdc tien hanh ngay sau khi phong van.
Cac thong tin thu dtfdc khi phong van co the dtfdc xac minh qua tham
kham thtfc the.
- Kham thQc the dQdc tien hanh mot cach he thong, cac thdng tin cd ban thu
98
thap nha dau hieu sinh ton, can nang, chieu cao, tiep den kham xet ttf dau
den chan, dtfa theo cau true, chiic nang cac bo may cua cO the de kham.
- Khi tham kham thtfc the stf dung cac ky thuat.
+ Quan sat.
+ Sd, nan: sii dung doi ban tay de sd, nan va thu thap thong tin: nhtf
dem mach, do nhiet do, veo da de danh gia mtfc do dan hoi cua no.
+ Go: go cac cd quan cua cd the de tao ra cac rung dong va am thanh de
thu nhan thong tin.
+ Nghe: la qua trinh nghe cac am thanh cua cd the trong bo may ho hap,
tuan hoan, va tieu hoa, ong nghe la dung cu dtfdc stf dung rat thong dung.
- Nhtfng diem can ltfu y khi tham kham thtfc the ngtfdi benh.
+ Phai giai thich ro rang cho ngtfdi benh hieu, ngtfdi dieu dtfdng se lam gi
trong khi tham kham, va chi dtfdc kham ngtfdi benh khi ho cho phep.
+ Co du anh sang tot nhat la anh sang ttf nhien.
+ Dam bao stf kin dao trong khi tien hanh kham, chi dtfdc de lo ra phan
cd the se dtfdc tham kham va chi keo dai du thdi gian can thiet de
hoan thanh viec tham kham.
+ Trong suot qua trinh tham kham, can phai so sanh thong tin thu thap
dtfdc vdi “nhtfng gia tri binh thtfdng”.
+ Cac thong tin thu dtfdc nen ghi chep lai trong qua trinh kham, vi chd
den khi kham xong mdi ghi lai co the mot so" thong tin se mat chinh xac.
+ Ket thuc qua trinh tham kham phai xac dinh dtfdc nhiing diem bat
thtfdng ma ttf do co the chi ra cac van de stfc khoe trtfdc kia, hien tai
va ttfdng lai cua ngtfdi benh.
+ Khi kham xong de ngtfdi benh cf ttf the thoai mai.
2.5.3. Ket qua xet nghiem
- Cac xet nghiem dtfdc chon loc dtfa theo cac trieu chtfng va benh tat cua
ngtfdi benh. Cac xet nghiem la do bac si yeu cau, tuy nhien cac ket qua
xet nghiem can dtfdc stf dung de bo sung cho nhan dinh dieu dtfdng dtfdc
chinh xac.
- Cac xet nghiem co the xac minh cac thong tin thu thap dtfdc va giup hinh
thanh ke hoach cham soc ngtfdi benh dung.
3. CHAN D O AN D IE U Dl/ClNG
- Ket thuc phan nhan dinh ngtfdi benh, ngtfdi dieu dtfdng phai dtfa ra dtfdc
cac chan doan dieu dtfdng " Chan doan dieu dtfdng la neu len van de hien
99