Course: Nursing Process and Documentation

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Course title Nursing Process and Documentation
Course code UZV/O2OD
Organizational form of instruction Lecture + Tutorial
Level of course Bachelor
Year of study not specified
Semester Summer
Number of ECTS credits 3
Language of instruction Czech
Status of course Compulsory
Form of instruction Face-to-face
Work placements This is not an internship
Recommended optional programme components None
Lecturer(s)
  • Schneider Michaela, PhDr. Ph.D., MBA
Course content
Lectures - Nursing process - concept, historical development, importance and use in practice - 1 hour - Overview of phases of nursing process - 1 hour - Assessment of the patient (assessment), ie. obtaining information about the patient, sources, record - 1 hour - Nursing diagnostics - 1 hour - Taxonomy NANDA, NIC, NIGHT, ICNP - 2 hrs. - Nursing care planning, goal formulation and nursing intervention plan - 1 hour - Implementation of planned care, competence of individual members of the medical team - 1 hour. - Evaluation of the effectiveness of nursing care - evaluation - 1 hour - Nursing documentation, legal aspects of nursing documentation - 1 hour Class practice - Assessment steps (collection, analysis and organization of information, selection of potential diagnoses, in-depth assessment, prioritization and diagnosis) - 2 hours - Methods of obtaining information and data - 2 hours - Diagnostic process, determination (formulation) of nursing diagnosis - 2 hours - Creation of nursing plan - 2 hours - Realization of nursing care - 2 hours - Evaluation - 2 hours - Medical documentation, record in nursing documentation - practice documentation - 2 hours - Work with documentation in the given department under professional supervision - internship in the clinical department - 4 hours. - Procedure of developing a nursing plan for a specific client (and with the modified identification data) - 2 hours

Learning activities and teaching methods
Lecturing, Monologic (Exposition, lecture, briefing), Dialogic (Discussion, conversation, brainstorming), Methods for working with texts (Textbook, book), Observation, Demonstration, Practice exercises, Text analysis, Self-reflection, Students working in pairs, Dealing with situational issues - learning in situations
learning outcomes
Knowledge
describe and explain in your own words the nursing process
describe and explain in your own words the nursing process
describe the historical development and individual phases of the nursing process
describe the historical development and individual phases of the nursing process
identify nursing problems of the client
identify nursing problems of the client
list the parts of the medical documentation and clarify its meaning
list the parts of the medical documentation and clarify its meaning
explain the principles of nursing documentation management
explain the principles of nursing documentation management
Skills
take an anamnesis, perform a physical examination of a specific patient/client
take an anamnesis, perform a physical examination of a specific patient/client
evaluate the condition of the patient/client
evaluate the condition of the patient/client
formulate nursing diagnoses
formulate nursing diagnoses
draw up a nursing plan for the goals of care for a specific patient/client
draw up a nursing plan for the goals of care for a specific patient/client
make correct entries in the nursing documentation
make correct entries in the nursing documentation
teaching methods
Knowledge
Demonstration
Demonstration
Dialogic (Discussion, conversation, brainstorming)
Dialogic (Discussion, conversation, brainstorming)
Methods for working with texts (Textbook, book)
Methods for working with texts (Textbook, book)
Observation
Observation
Text analysis
Text analysis
Self-reflection
Self-reflection
Practice exercises
Practice exercises
Students working in pairs
Students working in pairs
Lecturing
Dealing with situational issues - learning in situations
Dealing with situational issues - learning in situations
Lecturing
Monologic (Exposition, lecture, briefing)
Monologic (Exposition, lecture, briefing)
assessment methods
Analysis of another type of paper written by the student (Casuistry, diary, plan ...)
Analysis of another type of paper written by the student (Casuistry, diary, plan ...)
Analysis of the student's performance
Analysis of the student's performance
Written examination
Written examination
Recommended literature
  • Kontakt, Profese, Ošetřovatelství a porodní asistence, British Journal of Nursing, RN, Nursing aj..
  • BULECHEK, G. M., BUTCHER, H. K., DOCHTERMAN, J. M. Nursing Interventions Classification (NIC). Mosby, 2008. ISBN 978-0-323-05340-2.
  • HERDMAN, T. H., KAMITSURU, S. (eds.). Ošetřovatelské diagnózy: definice a klasifikace 2018-2020. Prah: Grada, 2020.
  • HERDMAN, T.H. & KAMITSURU, S., překlad Pavla Kudlová. NANDA International, Inc. OŠETŘOVATELSKÉ DIAGNÓZY: Definice a klasifikace 2015-2017. Praha: Grada, 2015. ISBN 978-80-247-5412-3.
  • Kolektiv autorů. Průvodce ošetřovatelskou dokumentací od A do Z. 1. vyd. Praha: Grada Publishing, 2002. ISBN 80-247-0278-9.
  • KUDLOVÁ, P. a J. MAREČKOVÁ. Ošetřovatelská dokumentace, plán ošetřovatelské péče ? výstup 3. fáze ošetřovatelského procesu. Olomouc: Grada, 2004.
  • KUDLOVÁ, P. Historie ošetřovatelského procesu a ošetřovatelských diagnóz NANDA. In Ošetřovatelství - morální umění. Krátká, Kutnohorská, Cichá a kol. Praha: Grada, 2011. ISBN 978-80-247-4201-4.
  • MASTILIAKOVÁ, D. Posuzování stavu zdraví a ošetřovatelská diagnostika: v moderní ošetřovatelské praxi. Praha: Grada, 2014.
  • MOORHEAD, S. Nursing Outcomes Classification (NOC). Oxford: MOSBY ELSEVIER, 2012. ISBN 978-0-323-05408-9.
  • NEJEDLÁ Marie. Fyzikální vyšetření pro sestry. Praha: Grada, 2006. ISBN 80-247-1150-8.
  • PACOVSKÝ, V. Ošetřovatelská diagnostika. Praha: UK, 1985.
  • TÓTHOVÁ, Valerie a kol. Ošetřovatelský proces a jeho realizace. Praha: Triton, 2014. ISBN 978-80-7387-785-9.
  • TRACHTOVÁ, E. et al. Potřeby nemocného v ošetřovatelském procesu. 2. vyd. Brno: IDVPZ, 2001.
  • VAŠÁTKOVÁ, I. a kol. Ošetřovatelská dokumentace v nemocnici. Brno: IDVPZ, 2001. ISBN 80-7013-327-9.


Study plans that include the course
Faculty Study plan (Version) Category of Branch/Specialization Recommended year of study Recommended semester