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Upute o voenju sestrinske liste, su kratak vodi kroz Sestrinsku listu i njezine sastavnice, a u cilju lakeg voenja same liste i lakeg koritenja dobivenih podataka. Klasi kacijski podaci koji su koriteni u sastavljanju Sestrinske liste, prilagoeni su potrebama za zdravstvenom njegom u RH, te usklaeni s edukacijskim programom sestrinstva u RH. Sestrinska lista je sastavljena na nain da sestre mogu procijeniti pacijentovo stanje i na osnovi toga donijeti odreene zakljuke, dijagnosticirati problem i odrediti koliinu sestrinske skrbi za odreenog pacijenta, te na taj nain poboljati kvalitetu zdravstvene njege. Klasi kacija sestrinskih dijagnoza, ciljeva i intervencija smatra se jednim od najveih postignua u sestrinstvu. Istodobno je to instrument daljnjeg razvoja u sestrinstvu i zdravstvu openito. Sestrinska lista biti e osnova koja e pruiti bazu podataka za razvoj sestrinskog dijela zdravstvene informatike, omoguiti sestrinska istraivanja, pruati osnove za obrazovanje medicinskih sestara, garantirati i unaprjeivati kvalitetu zdravstvene njege, te stoga biti vrlo korisna i za Ministarstvo zdravstva i socijalne skrbi. Svrha jedinstvene dokumentacije s minimalnim setom podataka autorsko je djelo Majde i Oscara De Miranda. Pri izradi sestrinske liste nastojali smo strunu terminologiju uskladiti sa svjetskim i europskim standardima. Za usklaivanje podataka koji su potrebni u zdravstvenoj njezi koriteni su slijedei predloci: obrasci zdravstvenog funkcioniranja M. Gordon MNDS - minimalnog seta podataka u zdravstvenoj njezi ICNP - International Classi cation for Nursing Practice, djelomino, jer je sistem u razvoju NANDA - Klasi kacija sestrinskih dijagnoza dosadanja iskustva, steena uvidom u razliite oblike sestrinske dokumentacije razliitih odjela u bolnicama RH edukacijski program sestrinskog obrazovanja u RH.

Sestrinska lista je sastavljena prema Obrascima zdravstvenog funkcioniranja M. Gordon. Obuhvaene su osnovne ljudske potrebe, koje su djelokrug rada medicinskih sestara. Sestrinska lista je predviena za upotrebu u svakodnevnoj praksi, na razini medicinska sestra - pacijent, na bolnikim odjelima, za pacijente koji borave na odjelima due od 24 sata. Dobiveni podaci se mogu koristiti u istraivake i edukacijske svrhe, a pacijent na vlastiti zahtjev moe dobiti uvid u Listu.

Sestrinska lista se sastoji od vanjskog dijela, na A3 formatu i umetnutih sastavnica.

1. strana Sestrinske liste sadri sestrinsku anamnezu (MNDS: demografski podaci o pacijentu,elementi zdravstvene njege - obrasci zdravstvenog funkcioniranja,elementi servisnih institucija vanih za ZNJ)

2. strana sadri nastavak s prethodne strane, zikalni pregled od glave do pete, sestrinske dijagnoze i osobitosti o pacijentu.

UPUTE O VOENJU SESTRINSKE LISTE


Ovi podaci moraju biti prikupljeni tijekom 24 sata od prijama pacijenta. Sestrinske dijagnoze, ciljeve i intervencije odreuje via medicinska sestra. Ciljeve i intervencije odreuje u dogovoru s pacijentom.

3. strana je praenje stanja pacijenta tijekom hospitalizacije. Ovdje se svakodnevno upisuju stupnjevi Samozbrinjavanja i Fizikih aktivnosti tijekom hospitalizacije, bodovi skala (Braden, Glasgow/trauma skor, Morse-rizik za pad tablice su u prilogu), broj razine bola, DA/NE za toleranciju napora. Rubrika kategorizacije e se popunjavati kada e biti odreena kategorizacija pacijenata.

Skale su preporuene i imaju potvrenu sigurnost u istraivakom radu. Braden skala za procjenu rizika za nastanak dekubitusa je najkoritenija skala i ima potvrenu valjanost, za razliku od drugih skala. trajno praenje postupaka - provodi se sukladno preporukama na dnu liste, a mogu se, osim navedenih postupaka, upisati i drugi postupci. Na taj nain se omoguava brz uvid u ope stanje pacijenta, te brza procjena za trenutanom potrebom kadrova na odjelu.

Strana 3a se moe umetnuti kao dodatak ako pacijent boravi due vrijeme u bolnici.

4. strana - upisuju se medicinsko - tehniki i dijagnostiki postupci, koji su ordinirani, planirani i obavljeni tijekom hospitalizacije. U primjedbe se upisuju eventualne promjene i zbivanja vezana uz postupak.

Br. 5 Trajno praenje stanja pacijenta (decursus) upisuju se sve promjene kod pacijenta tijekom 24 sata (simptomi, znaci, opisi novonastalog stanja, mogui uzroci).

Br. 6 Plan zdravstvene njegeizrauje via medicinska sestra sukladno utvrenim potrebama za zdravstvenom njegom. Sestrinske dijagnoze se evidentiraju prema PES modelu (P=problem, E=etiologija, S=simptom) za aktualne dijagnoze, te po PE modelu za visokorizine dijagnoze. Ciljevi i intervencije - sestrinski postupci, de niraju se u dogovoru s pacijentom. Provedeni postupci iz plana evidentiraju se na listi 6a Lista provedenih sestrinskih postupaka. Evaluacija se upisuje prema zadanom cilju, a moe biti trajna, dnevna, tjedna i zavrna.

Ostale sastavnice Sestrinske listeBr. 7 Evidencija ordinirane i primijenjene terapije uz svaku primjenu lijeka medicinska sestra mora upisati vrijeme davanja lijeka i potpisati se.

Br. 8 Unos i izluivanje tekuineprimjenjuje se kod pacijenata kod kojih je potrebno pratiti unos i izluivanje tekuina kroz 24 sata.

Br. 9 Procjena bola primjenjuje se kod pacijenata koji imaju uestalu ili trajnu bol. Uz primjenu lijekova ili distraktora, potrebno je upisati i uinak istih - evaluacija. Uestalost procjene je individualna.


Br. 10 Lista za praenje dekubitusavodi se kod pacijenata kod kojih je prisutan dekubitus. Svaku promjenu poloaja sestra evidentira zaokruivanjem vremena i potvruje svojim inicijalima u rubriku uz odgovarajui poloaj.Uz dijagnozu Visok rizik za nastanak dekubitusa, VMS e ordinirati postupke u listu br. 6.

Br. 11 Nadzorna lista rizinih postupaka u zdravstvenoj njezilista slui za upis moguih komplikacija nakon medicinsko tehnikih postupaka, kod pacijenata kod kojih je prisutan vei rizik za pojavu komplikacija. (Npr.: uvoenje NG sonde ili lavaa unutarnjih organa kod hipotermije, bronhoaspiracija kod pacijenata s trombocitopenijom, kateterizacija urina kod pacijenata s trombocitopenijom ili pancitopenijom...)

Br. 12 Izvijee o incidentuSprijeenom ili nastalom moe se pisati u vie primjeraka, sukladno pravilima Ustanove, a jedan primjerak obavezno ostaje u Sestrinskoj listi.

Br. 13 Otpusno pismo zdravstvene njegeizdaje se za pacijente kod kojih je potreban nastavak zdravstvene njege. Pismo se pie u vie primjeraka, a jedan primjerak obavezno ostaje u Sestrinskoj listi. Otpusno pismo se alje patronanoj slubi prema mjestu stanovanja, ili nadlenoj sestri kod premjetaja u drugu ustanovu ili odjel.

Otpusno pismo su izradili:Majda de Miranda B.Sc.prof.Health Education, RN, Senior advisorOscar R. de Miranda M.Sc.Med.Soc., M.Sc.OD,Ph.D.NSc, RN, Senior advisor,uz nekoliko sugestija tima za izradu Sestrinske liste.

Poseban prilog:1 - Mogue sestrinske dijagnoze2 - Lista okretanja pacijenata

POSEBNE NAPOMENESestrinska lista je obavezna od broja 1 do broja 6 i 6a. Sastavnice Sestrinske liste Br. 7, 8, 9, 10, 11, 12 i 13 upotrebljavaju se ovisno o potrebama. Isto tako, ovisno o speci nostima pojedinih odjela ili ustanova, mogu se izraditi sastavnice koje su speci ne za taj odjel ili ustanovu. Sestrinska lista nije prilagoena odjelima na kojima postoji speci na potreba za zdravstvenom njegom, npr., neonatologija. Te Liste se mogu izraditi ukoliko se ukae potreba za jedinstvenom listom na nacionalnoj razini, ali one ne predstavljaju MNDS podataka.

Koritena literatura za izradu sestrinske liste:Snjeana ukljek, 2005.: Osnove zdravstvene njegeGordana Fukar, 1996.: Uvod u sestrinske dijagnozeICNP BETA 2 2001.Nursing Diagnoses: De nitions & Classi cation 2005-2006, NANDA, 2005. Brief Synopsis of the Nursing Minimum Data Set (NMDS), 2003.,


Majda i Oscar De Miranda sudjelovali su u izradi Sestrinske liste korisnim savjetima i ulaganjem svojeg velikog strunog znanja. Tim koji je izradio Sestrinsku listu: Slavica epec, vms, glavna sestra odjela Klinike za plune bolesti Jordanovac, mentor za

zdravstvenu njegu na Zdravstvenom veleuilitu u Zagrebu Snjeana ukljek, vms, prof., predava na Zdravstvenom veleuilitu u Zagrebu Ruica Graak, vms, glavna sestra Specijalne bolnice za plune bolesti Rockfellerova, mentor

za zdravstvenu njegu na Zdravstvenom veleuilitu u Zagrebu Ruica Evai, vms, glavna sestra Interne djelatnosti Ope bolnice Tomislav Bardek u

Koprivnici, nastavnik u koli za medicinske sestre u Koprivnici Ana Ljubas, vms, glavna sestra Kardioloke klinike KBC Rebro, mentor za zdravstvenu njegu

na Zdravstvenom veleuilitu u Zagrebu Zvjezdana Betek - Smajilovi, vms, glavna sestra odjela abdominalne kirurgije Klinike bolnice

Dubrava, mentor za zdravstvenu njegu na Zdravstvenom veleuilitu u Zagrebu Vesna Stui, vms, glavna sestra Interne klinike KB Merkur, mentor za zdravstvenu njegu na

Zdravstvenom veleuilitu u Zagrebu Nada Hrdan, vms, glavna sestra Dijalize i nefrologije Klinike za dijabetes Vuk Vrhovec, mentor

za zdravstvenu njegu na Zdravstvenom veleuilitu u Zagrebu

Zagreb, studeni 2005. godine.


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