Introduction The correct drawing up of the nursing record represents a duty for all the professionals and the method by which support the care planning and express the patient treatment. In a complex environment such as the pediatric nursing care, it’s necessary to have a tool able to carry out the care planning with the principles of Family Centered Care, placing at the center of the nursing process not only the child, but the whole family necessarily involved by the experience of the disease. In order to promote care planning in the pediatric field, it is necessary to work with both nurses and students in training. Purposes The project’s purposes are mainly three. First of all, it was created the single form of nursing documentation by the nurses of Pediatrics, Clinic of Pediatrics, Infectious Diseases, Infantile Neuropsychiatry, Neonatology and Pediatric Surgery of the Hospital "G . Salesi "in Ancona. The training course for nurses was structured with ECM accreditation methods, linked to the implementation of the tool in the hospital wards. Finally, the tool created was tested by nursing students using clinical cases created by expert staff in pediatrics. Materials and methods After the bibliographic research using Google Scholar and PubMed, were structured three training activities. Coordinators, nurses and nursing tutors took part to the accredited improvement activity "Nursing clinical assessment in the maternal and child sector”; after five meetings the Nursing Record was created as a single form implemented in the reference departments. At the end of the improvement activity, it emerged the need to involve all the ward nurses to promote the tool just carried out and to practice in care planning and to familiarize themselves with the new documentation available. For this purpose, it has been organized three meetings, but because of the health emergency it was considered appropriate to postpone this training experience. For the involvement of the students, according with the professionals of the NICU and Pediatric Resuscitation of Salesi, contents were shared through the Moodle platform and the students were asked to work on care planning by using the tool carried out, starting from clinical cases designed by the experts. Results and discussion A new nursing record was created with an attached standardized care planning proposal implemented in the wards. The work with the students made it possible to evaluate their ability to identify nursing diagnoses, aims and priority interventions through the analysis of proposed cases, simulating care in a safe environment for the patient. Conclusion The tool created responded to the growing need of nursing documentation and investments in training in the maternal and child sector. The simultaneous involvement of the internship guides and nursing students has made possible the continuous training of professionals together with the university training of students, choosing to deepen a complex aspect such as that of care planning, a necessary activity, but which often meets too many obstacles.
Introduzione La corretta compilazione della cartella infermieristica è un obbligo per i professionisti e il mezzo attraverso il quale sostenere la pianificazione assistenziale ed esprimere la presa in carico dell’assistito. In un ambito complesso come quello dell’assistenza infermieristica in pediatria è necessario possedere uno strumento che concepisca la pianificazione assistenziale con i principi del Family Centered Care, ponendo al centro del processo di nursing non solo il bambino, ma tutta la famiglia necessariamente coinvolta dall’esperienza della malattia. Affinché venga incentivata la pianificazione assistenziale in ambito pediatrico è necessario lavorare insieme ai professionisti della salute e insieme agli studenti in formazione. Obiettivi Gli obiettivi del progetto sono stati principalmente tre. In primo luogo, è stato realizzato il modello unico di documentazione infermieristica basato sulla condivisione dello strumento da parte delle SOD del Dipartimento Materno Infantile, nello specifico Pediatria, Clinica di Pediatria, Malattie infettive, Neuropsichiatria infantile, Neonatologia e Chirurgia Pediatrica del Presidio Ospedaliero "G. Salesi" dell’Azienda O.U. Ospedali Riuniti di Ancona, che dovranno utilizzarlo. Si è poi strutturato il corso di formazione per il personale sanitario con modalità di accreditamento ECM, per implementare lo strumento nelle SOD di riferimento. Infine si è sperimentato lo strumento realizzato con gli studenti del terzo anno del CdL in Infermieristica dell’Università Politecnica delle Marche utilizzando casi clinici creati dal personale esperto in pediatria. Materiali e metodi Insieme alla ricerca bibliografica, per cui sono stati utilizzati il motore di ricerca Google Scholar e la banca dati PubMed, sono state strutturate 3 attività formative. Con l’attività di miglioramento accreditata “L’accertamento clinico infermieristico in ambito materno infantile” sono stati coinvolti coordinatori ed infermieri delle SOD sopra elencate insieme ai tutor del CdL in Infermieristica della sede di Ancona; attraverso 5 incontri è stata realizzata la Cartella Infermieristica implementata nei reparti di riferimento. Al termine dell’attività di miglioramento è emerso il bisogno di rivolgersi a tutti gli infermieri appartenenti alle SOD coinvolte per presentare lo strumento prodotto ed esercitarsi nella pianificazione assistenziale per familiarizzare con la nuova documentazione disponibile. Per permettere questo sono stati strutturati 3 incontri; a causa dell’emergenza sanitaria si è ritenuto opportuno posticipare questa esperienza formativa. Per il coinvolgimento degli studenti, insieme ai professionisti della TIN e della Rianimazione Pediatrica del Salesi, sono stati condivisi dei contenuti attraverso la piattaforma Moodle ed è stato chiesto agli studenti di lavorare sulla pianificazione assistenziale attraverso lo strumento realizzato partendo da casi clinici ideati dagli esperti. Risultati e discussione E’ stata realizzata una nuova cartella infermieristica con allegata proposta di pianificazione assistenziale standardizzata implementata nei reparti. Il lavoro con gli studenti ha permesso di valutare la loro capacità di individuare le diagnosi infermieristiche, obiettivi ed interventi prioritari attraverso l’analisi di casi proposti, simulando l’assistenza in un ambiente sicuro per il paziente. Conclusione Lo strumento realizzato ha risposto all’esigenza di lavorare per incrementare la documentazione infermieristica e investire nella formazione in ambito materno infantile. Il coinvolgimento delle guide di tirocinio e degli studenti del CdL in Infermieristica ha permesso di far convergere la formazione continua dei professionisti con quella universitaria degli studenti, scegliendo di approfondire un aspetto complesso come quello della pianificazione assistenziale, attività necessaria, ma che incontra numerosi ostacoli.
Implementazione dell'utilizzo della documentazione infermieristica e della pianificazione assistenziale nell'ambito pediatrico
ANDREONI, ANNACHIARA
2019/2020
Abstract
Introduction The correct drawing up of the nursing record represents a duty for all the professionals and the method by which support the care planning and express the patient treatment. In a complex environment such as the pediatric nursing care, it’s necessary to have a tool able to carry out the care planning with the principles of Family Centered Care, placing at the center of the nursing process not only the child, but the whole family necessarily involved by the experience of the disease. In order to promote care planning in the pediatric field, it is necessary to work with both nurses and students in training. Purposes The project’s purposes are mainly three. First of all, it was created the single form of nursing documentation by the nurses of Pediatrics, Clinic of Pediatrics, Infectious Diseases, Infantile Neuropsychiatry, Neonatology and Pediatric Surgery of the Hospital "G . Salesi "in Ancona. The training course for nurses was structured with ECM accreditation methods, linked to the implementation of the tool in the hospital wards. Finally, the tool created was tested by nursing students using clinical cases created by expert staff in pediatrics. Materials and methods After the bibliographic research using Google Scholar and PubMed, were structured three training activities. Coordinators, nurses and nursing tutors took part to the accredited improvement activity "Nursing clinical assessment in the maternal and child sector”; after five meetings the Nursing Record was created as a single form implemented in the reference departments. At the end of the improvement activity, it emerged the need to involve all the ward nurses to promote the tool just carried out and to practice in care planning and to familiarize themselves with the new documentation available. For this purpose, it has been organized three meetings, but because of the health emergency it was considered appropriate to postpone this training experience. For the involvement of the students, according with the professionals of the NICU and Pediatric Resuscitation of Salesi, contents were shared through the Moodle platform and the students were asked to work on care planning by using the tool carried out, starting from clinical cases designed by the experts. Results and discussion A new nursing record was created with an attached standardized care planning proposal implemented in the wards. The work with the students made it possible to evaluate their ability to identify nursing diagnoses, aims and priority interventions through the analysis of proposed cases, simulating care in a safe environment for the patient. Conclusion The tool created responded to the growing need of nursing documentation and investments in training in the maternal and child sector. The simultaneous involvement of the internship guides and nursing students has made possible the continuous training of professionals together with the university training of students, choosing to deepen a complex aspect such as that of care planning, a necessary activity, but which often meets too many obstacles.| File | Dimensione | Formato | |
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CdLM.Andreoni Annachiara def.pdf
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https://hdl.handle.net/20.500.12075/4392