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Received: 12 November 2020 / / Accepted: 04 February 2021 / Published online: 30 March 2021
DOI 10.34689/SH.2021.23.1.002 UDC 614.253.52 (578.834.1
DEVELOPMENT AND IMPLEMENTATION OF NURSING DOCUMENTATION ON CORONAVIRUS INFECTION (COVID-19)
AT THE NURSING LEVEL
Dariga S. Smailova 1, http://orcid.org/0000-0002-7152-7104 Bibinur K. Sydykova 1, https://orcid.org/0000-0002-7013-3461 Gulzat Z. Sarsenbayeva 2,
Aidos K. Bolatov 3, https://orcid.org/0000-0002-5390-4623 Gulnara A. Mussina 4, Zaure А. Baigozhina 5, Zaituna A. Khismetova 1, https://orcid.org/0000-0001-5937-3045
1 NCJSC «Semey Medical University», Semey city, the Republic of Kazakhstan;
2 JSC «South Kazakhstan Medical Academy», Shymkent city, the Republic of Kazakhstan;
3 NJSC «Astana Medical University», Nur-Sultan city, the Republic of Kazakhstan;
4 MSE on the REM « Polyclinic number 4 of the city of Pavlodar », Pavlodar city, the Republic of Kazakhstan;
5 The Republican state enterprise on the right of economic management "Republican Center for Healthcare Development", Nur-Sultan city, the Republic of Kazakhstan.
Abstract
Introduction: The coronavirus infection COVID-19 caused by SARS-CoV-2 continues to spread rapidly around the world. On March 11, 2020, the WHO declared an outbreak of coronavirus infection a pandemic. The first case in Kazakhstan was registered on March 13, 2020. On March 16, a state of emergency was declared in Kazakhstan. Since March 19, quarantine has been introduced in Nur-Sultan and Almaty. From March 20, confirmed cases of COVID-19 began to be registered in other regions of the country. Since March 30, quarantine has been introduced in other cities of the country. Therefore, the maintenance of nursing documentation on coronavirus infection at the nursing level plays an important role.
Aim: Increase the level of care at the nursing level in the context of the global coronavirus infection (COVID-19) pandemic by introducing nursing documentation.
Methods: Within the framework of this study, international and domestic experience in the fight against COVID-19 was studied. The incidence and mortality of COVID-19 in the world and in Kazakhstan has been studied. The nursing documentation form (checklist) was developed using the adapted Clinical Care Classification of the International Nursing Practice Classifier.
Results: As of January 18, 2021, a total of 171,232 cases were detected in the Republic of Kazakhstan, of which 155,397 patients recovered, 2,403 cases with a lethal outcome were registered. To improve the provision of care to patients at the nursing level, a form for nursing documentation has been developed "Nursing reception and nursing care during the initial visit of the patient to the out-patient department/filter with signs of SARS, including COVID-19". According to the survey on a 10-point scale, 70.7% of the survey participants rated this form at 6-10 points, including 37.6% at 10 points.
Conclusion: The analysis made it possible to identify the nature of the epidemiological situation for coronavirus infection COVID-19 in the world, which served as the basis for the development of nursing documentation to improve preventive measures to combat coronavirus infection at the nursing process level.
Keywords: COVID-19, pandemic, epidemiology, Kazakhstan, nursing documentation
Резюме
РАЗРАБОТКА И ВНЕДРЕНИЕ СЕСТРИНСКОЙ ДОКУМЕНТАЦИИ ПО КОРОНАВИРУСНОЙ ИНФЕКЦИИ (COVID-19) НА УРОВНЕ СЕСТРИНСКОГО ПРОЦЕССА
Дарига С. Смаилова 1, http://orcid.org/0000-0002-7152-7104 Бибшур К- Сыдыкова 1 https://orcid.org/0000-0002-7013-3461 Гульзат Ж. Сарсенбаева 2,
Айдос К. Болатов 3, https://orcid.org/0000-0002-5390-4623 Гульнара А. Мусина 4, Зауре А. Байгожина 5 Зайтуна А. Хисметова 1, https://orcid.org/0000-0001-5937-3045
1 НАО «Медицинский университет Семей», г. Семей, Республика Казахстан;
2 АО «Южно-Казахстанская медицинская академия», г. Шымкент, Республика Казахстан;
3 НАО «Медицинский университет Астана», г. Нур-Султан, Республика Казахстан;
4 КГП на ПХВ «Поликлиника № 4 г. Павлодар», г. Павлодар, Республика Казахстан;
5 РГП на ПХВ «Республиканский центр развития здравоохранения» МЗ РК, г. Нур-Султан, Республика Казахстан.
Введение: Коронавирусная инфекция COVID-19 вызванная SARS-CoV-2 продолжает быстро распространяться по всему миру. 11 марта 2020 года Всемирной организацией здравоохранения вспышка коронавирусной инфекцией объявлена пандемией. Первый случай в Казахстане был зарегистрирован 13 марта 2020 года. 16 марта в Казахстане введено чрезвычайное положение. С 19 марта карантин введен в г.Нур-Султан и Алматы. С 20 марта подтвержденные случаи COVID-19 начали регистрировать в других регионах страны. С 30 марта карантин введен и в других городах страны. Поэтому немаловажную роль играет ведение сестринской документации по коронавирусной инфекции на уровне сестринского процесса.
Цель: повысить уровень оказания медицинской помощи на уровне сестринского процесса в условиях глобальной пандемии коронавирусной инфекции (COVID -19) путем внедрения сестринской документации.
Методы: В рамках данного исследования изучен международный и отечественный опыт в борьбе с коронавирусной инфекцией (КВИ). Изучена заболеваемость и смертность COVID-19 в мире и Казахстане. Форма сестринской документации (чек-лист) была разработана с использованием адаптированного Международного классификатора сестринской практики Clinical Care Classification.
Результаты: По состоянию на 18 января 2021 года всего в Республике Казахстан выявлено 171232 заболевших, из них выздоровели 155397 пациентов, зарегистрировано 2403 случая с летальным исходом. С целью улучшения оказания помощи пациентам на сестринском уровне, разработана форма сестринской документации «Сестринский прием и сестринский уход при первичном обращении пациента в поликлинику/фильтр с признаками ОРВИ, в том числе COVID-19». Согласно опросу по 10-бальной шкале 70,7% участников анкетирования оценили данную форму на 6-10 баллов, в том числе 37,6% на 10 баллов.
Заключение: Проведенный анализ позволяет выявить характер эпидемиологической ситуации по коронавирусной инфекции COVID-19 в мире, что послужил основой для разработки сестринской документации с целью улучшения превентивных мероприятий по борьбе с коронавирусной инфекцией на уровне сестринского процесса.
Ключевые слова: COVID-19, пандемия, эпидемиология, Казахстан, сестринская документация
Туйшдеме
МЕЙ1РГЕРЛ1К ДЕНГЕЙДЕ КОРОНАВИРУСТЫК ИНФЕКЦИЯ (COVID-19) БОЙЫНША МЕЙ1РГЕРЛ1К КУЖАТТАМАНЫ ЭЗ1РЛЕУ ЖЭНЕ ЕНГ1ЗУ
Дарига С. Смаилова 1, http://orcid.org/0000-0002-7152-7104 Бибшур К- Сыдыкова 1 https://orcid.org/0000-0002-7013-3461 Гульзат Ж. Сарсенбаева 2,
Айдос К. Болатов 3, https://orcid.org/0000-0002-5390-4623 Гульнара А. Мусина 4, Зауре А. Байгожина 5, Зайтуна А. Хисметова 1, https://orcid.org/0000-0001-5937-3045
1 «Семей медицина университет» КеАК, Семей к., Казахстан Республикасы.
2 «Оцтустш Казакстан медицина академиясы» АК, Шымкент к-, Казакстан Республикасы.
3 «Астана медицина университет» КеАК, Нур-Султан к., Казакстан Республикасы.
4 ШЖК «Павлодар капасыньщ №4 емханасы» КМК, Павлодар к., Казакстан Республикасы.
5 «Денсаулык сактауды дамыту Республикалык орталыгы» ШЖК РМК, Нур-Султан к., Казакстан Республикасы.
К1р1спе: SARS-CoV-2 туындаткан коронавирустык COVID-19 инфекциясы 6y^ элемге тез таралуда. 2020 жылы 11 наурызда ДYниежYзiлiк денсаулык сактау уйымы коронавирустык инфекцияныщ эпидемиясын пандемия деп жариялады. Казакстанда алгашкы жавдай 2020 жылы 13 наурызда пркелдк 16 наурызда Казакстанда тетенше жавдай жарияланды. 19 наурыздан бастап карантин Нур-Султан мен Алматыда енпзтдк 20 наурыздан бастап COVID-19 расталган жавдайлары республиканыщ баска аймактарында пркеле бастады. 30 наурыздан бастап карантин елiмiздщ баска калаларында да енгiзiлдi. Сондыктан мейргерлк де^гейде коронавирустык инфекция бойынша мейргерлк кужаттаманы жYргiзу ма^ызды рел аткарады.
Максаты: Жаhандык коронавирустык инфекция (COVID-19) пандемиясы аясында мейiргерлiк денгейдегi кут1мнщ дечгейiн мейiргерлiк кужаттаманы енгiзу аркылы жаксарту.
Эдютер: Осы зерттеу аясында коронавирустык инфекциямен ^ресудщ халыкаралык ж8не отандык т8жiрибесi зерттелдг Элемде ж8не ^азакстанда COVID-19 ауруыныщ жиiлiгi мен влiмi зерттелдi. Мейргерлк кужаттама нысаны (бакылау тiзiмi) беймделген Халыкаралык мейiргердiк практика классификаторы Clinical Care Classification квмепмен жасалган.
Нэтижелер: 2021 жылгы 18 ка^тардагы жавдай бойынша ^азакстан Республикасында барлыгы 171 232 жавдай тiркелдi, оныщ 155 397 наукас сауыгып кеттi, влiммен аякталган 2403 жавдай тiркелдi. Мейргерлк дечгешнде пациенттерге квмек кврсетудi жаксарту максатында «Нау касты поликлиникага/фильтрге алгашкы кабылдау кезiндегi ЖРВИ белгiлерi бар, оныщ iшiнде COVID-19 мейiргерлiк кабылдау ж8не мейiргерлiк купм» мейiргерлiк кужаттама формасы 8зiрлендi. 10 баллдык шкала бойынша жYргiзiлген сауалнамага с8йкес, сауалнамага катысушылардыщ 70,7% -ы бул форманы 6-10 баллмен багалады, оныщ iшiнде 10 балл бойынша 37,6%.
Корытынды: Талдау 8лемдеп коронавирустык инфекцияныщ эпидемиологиялык жагдайыныщ сипатын аныктауга мYмкiндiк бердi, бул мейiргерлiк де^гейде коронавирустык инфекциямен ^ресудщ профилактикалык шараларын жетiлдiру максатында мейргерлк кужаттаманы жасауга негiз болды.
TYuiH свздер: COVID-19, пандемия, эпидемиология, Казахстан, мейргерлк кужаттама.
Bibliographic citation:
Smailova D.S., Sydykova B.K., Sarsenbayeva G.Z., Bolatov A.K., Mussina G.A., Baigozhina Z.A., Khismetova Z.A. Development and implementation of nursing documentation on coronavirus infection (COVID-19) at the nursing level // Nauka iZdravookhranenie [Science & Healthcare]. 2021, (Vol.23) 1, pp. 15-20. doi 10.34689/SH.2021.23.1.002
Смаилова Д.С., Сыдыкова Б.К., Сарсенбаева Г.Ж., Болатов А.К., Мусина Г.А., Байгожина З.А., Хисметова З.А. Разработка и внедрение сестринской документации по коронавирусной инфекции (COVID-19) на уровне сестринского процесса // Наука и Здравоохранение. 2021. 1(Т.23). С. 15-20. doi 10.34689/SH.2021.23.1.002
Смаилова Д.С., Сыдыкова Б.К., Сарсенбаева Г.Ж., Болатов А.К., Мусина Г.А., Байгожина З.А., Хисметова З.А. Мешргерлк де^гейде коронавирустык инфекция (COVID-19) бойынша мешргерлк кужаттаманы 8зiрлеу ж8не енпзу // Гылым ж8не Денсаулык сактау. 2021. 1 (Т.23). Б. 15-20. doi 10.34689/SH.2021.23.1.002
Introduction
The recent outbreak of COVID-19 in Wuhan has become a public health emergency of international concern. In the absence of antiviral drugs and vaccines and the presence of asymptomatic carriers, traditional public health interventions are significantly less effective [10]. Pneumonia caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) originated in Wuhan City, Hubei Province, China in December 2019. By February 11, 2020, the World Health Organization (WHO) has officially designated the disease resulting from infection with SARS-CoV-2 as the coronavirus disease 2019 (COVID-19). COVID-19 is a spectrum of clinical manifestations that usually include fever, dry cough, and fatigue, often involving the lungs. SARS-CoV-2 is highly contagious and most people are generally susceptible to infection. Wild animal hosts and infected patients are currently the main sources of the disease, which is transmitted through the respiratory tract and direct contact [9]. WHO issued a warning that while the new coronavirus infection COVID-19 from Wuhan, China is not a pandemic, it must be contained to prevent global spread [4]. On March 11, 2020, WHO declared an outbreak of coronavirus infection a pandemic [3]. Currently, COVID-19 patients are the main source of infection, and severe patients are considered more infectious than mild patients. The presence of symptoms of a respiratory infection has been associated with the release of the virus into the environment. However, asymptomatic individuals or patients in the incubation period who do not show signs or symptoms of respiratory infection can also be potential sources of infection [1]. 34.07% of cases of coronavirus infection COVID-19 were detected in asymptomatic individuals. Oran et al. Concluded that asymptomatic
patients account for 40% to 45% of confirmed cases of SARS-CoV-2 [12]. At the same time, Yanes-Lane et al. indicated that the proportion of asymptomatic infections at initial screening ranged from 20% to 75% of the general population [7]. Also, samples from COVID-19 patients consistently show a positive RT-PCR (reverse transcription-polymerase chain reaction) test [5], which has never been the case in the history of human infectious diseases. In other words, asymptomatically infected people and patients who are incubating or recovering from COVID-19 can pose major challenges to disease prevention and control [3].
The first cases of COVID-19 in Kazakhstan were detected on March 13 in Almaty and Nur-Sultan. On March 16, a state of emergency was declared in Kazakhstan. All schools were closed, and student education was transferred online. Since March 19, quarantine has been introduced in Nur-Sultan and Almaty. From March 20, confirmed cases of COVID-19 began to be registered in other regions of the country. On March 26, the first two patients were discharged in Nur-Sultan and Almaty, on the same day the first death from COVID-19 was registered in Nur-Sultan (64-year-old woman). Since March 30, quarantine has been introduced in other cities of the country [6]. The highest incidence rate in Kazakhstan was noted in the two largest cities - Nur-Sultan and Almaty. It should be noted that the first patients in the country were identified in these cities. In these cities, there are a high proportion of specialized medical institutions, where critically ill patients from neighboring regions are referred. The lowest incidence rate was noted in the East Kazakhstan and North Kazakhstan regions [8]. In connection with the current situation with COVID - 19 both in the world and in Kazakhstan, the role of medical workers, including nursing specialists, is increasing
in terms of their action in specific situations: work in infectious diseases and provisional hospitals, a polyclinic, as part of mobile teams, home hospital, in post-discharge rehabilitation, etc. So, an important role is played by the maintenance of nursing documentation on COVID-19 at the nursing level.
This study aims to improve the quality of care at the nursing level in the context of the global coronavirus infection (COVID-19) pandemic by introducing nursing documentation.
Materials and methods. The research design is descriptive. Within the framework of this study, international and domestic experience in the fight against COVID-19 was studied. Publications with a depth of 1 year, regulatory legal acts of the Republic of Kazakhstan were analyzed. The incidence and mortality of COVID-19 in the world and
Kazakhstan have been studied. Statistical data on morbidity and mortality from COVID-19 in the world and Kazakhstan were analyzed from the start of the pandemic to February 14, 2021.
The nursing documentation form (checklist) "Nursing reception and nursing care during the patient's initial admission to the out-patient department/filter with signs of SARS, including COVID-19" was developed using the adapted Clinical Care Classification of the International Nursing Practice Classifier. The form was rated on a 10-point scale by conducting an online survey among 180 nurses.
Results. Globally, as of February 16, 2021, 108,684,743 confirmed cases of COVID-19 were reported by the WHO, including 2,399,103 deaths. The highest incidence of COVID-19 is registered in the USA, India, and Brazil (Table 1).
Table 1.
Morbidity and mortality from COVID-19 by country according to WHO.
№ Country Number of COVID-19 cases, absolute number Number of deaths, absolute number
1 USA 27 309 503 480 464
2 India 10 925 710 155 813
3 Brazil 9 834 513 239 245
4 Russian Federation 4 086 090 80 520
5 United Kingdom 4 038 082 117 166
6 France 3406616 81 393
7 Spain 3 041 454 64 217
8 Italy 2 721 879 93 577
9 Turkey 2586 183 27 471
10 Germany 2 338 987 65 076
50 Kazakhstan 251 959 3 246
WHO source: https://covid19.who.int
As of February 14, 2021, 203,259 cases of COVID-19 and 2,540 deaths were registered in Kazakhstan. Thus, Kazakhstan ranks 50th out of 237 countries in terms of morbidity. The similar situation on morbidity and death is in Georgia. Table 2 provides information on the number of
Morbidity and mortality from COVID-19 in the context of
cases and deaths from COVID-19 in the context of the regions of the Republic of Kazakhstan. However Kazakhstani data differs from the World Health Organization.
Table 2.
ons of the Republic of Kazakhstan._
№ Region Morbidity, absolute number Number of deaths, absolute number
1 Nur-Sultan city 23884 385
2 Almaty city 23745 452
3 Shymkent city 6016 94
4 Akmola region 12709 104
5 Aktobe region 4102 50
6 Almaty region 10180 114
7 Atyrau region 16736 128
8 The East Kazakhstan region 21252 332
9 Jambyl Region 5772 64
10 West-Kazakhstan region 12171 199
11 Karaganda region 14778 307
12 Kostanay region 11506 40
13 Kyzylorda Region 3731 16
14 Mangistau region 4165 58
15 Pavlodar region 16411 107
16 North-Kazakhstan region 11882 42
17 Turkestan region 4219 48
Total 203 259 2540
Kazakhstani source: https://www.coronavirus2020.kz/
According to the ICD-10, COVID-19 is coded by medical personnel according to Table 3. However, according to the adapted International Classifier of Nursing
COVID-19 coding according to ICD-10._
Practice Clinical Care Classification, if detected by nurses, nursing diagnoses interventions can be coded (Table 4).
COVID-19 is and nursing
Table 3.
U07.1
COVID-19, virus identified
Use this code when COVID-19 has been confirmed by laboratory tests, regardless of the severity of the clinical signs or symptoms. If necessary, indicate pneumonia or other manifestations of infection, use the additional code._
U07.2
U07.2 COVID-19, virus not identified
Use this code if COVID-19 is diagnosed clinically or epidemiologically but laboratory tests are inconclusive or not available. If necessary, indicate pneumonia or other manifestations of infection, use the additional code._
Nursing diagnoses and nursing Classification of Nursing Practice.
interventions for COVID-19 using the adapted International
Table 4. Clinical Care
Nursing diagnosis Nursing interventions (care plan)
Sleep disturbance - A01.6 Sleep monitoring - A04.0
Diarrhea - B03.3 Increased bowel movements. Nausea - B04.1 Aversion to food/liquids leading to vomiting. Vomiting - B04.2 Diarrhea care - B06.4 Actions taken to control frequent bowel movements Control of nausea and vomiting - B62.1 Actions to control food aversion and vomiting.
Change in breathing - L26.0 Change/modification of breathing function. Breathing disorder - L26.2 Violation of the rhythm of breathing Disruption of gas exchange - L26.3 An imbalance in the transport of oxygen and carbon dioxide between the lungs and the circulatory system. Impaired ventilation - L56.0 Inability to enter and remove air from the respiratory tract. Oxygen therapy - L35.0 Actions performed using oxygen in treatment Caring for a patient with lung disease - L36.0 Steps taken to maintain lung hygiene Breathing exercises - L36.1 Actions to be taken for therapy during respiratory or pulmonary stress Inhalation therapy - L36.3 Actions to be taken to ensure breathing procedures Breathing apparatus care - L36.4 Steps taken to control and monitor the use of mechanical ventilation.
The form (checklist) "Nursing reception and nursing care during the initial admission of a patient to an outpatient department/filter with signs of SARS, including COVID-19" is published in the Guidelines for the development and implementation of nursing documentation in practical health care organizations and posted on the website of the Republican Center for Healthcare
Development http://www.rcrz.kz/index.php/ru/2017-03-12-10-51-13/metodicheskie-rekomendatsii.
According to the survey on a 10-point scale, 70.7% of the survey participants rated this form at 6-10 points, including 37.6% at 10 points.
Fig. 1 - Evaluation of the nursing documentation form «Nursing reception and nursing care during the patient's initial admission to the out-patient department/filter with signs of SARS, including COVID-19»
Discussion. According to a literature review in 2007, electronic nursing records in Finland were not unified and linked to the patient's medical history. The development of national unified and standardized nursing documentation for the use of standardized nursing data enables the management and assessment of the quality of the nursing
process and the integration of nursing documentation into a patient's multidisciplinary medical history [13]. Finnish nationally unified/adapted and standardized nursing documentation for the Finnish Care Classification was developed within the framework of the National Project in Finland during the period 2007-2008. Finland's electronic
health passports include information on nursing diagnosis, nursing intervention, and the outcome of nursing care, discharge [2]. In Kazakhstan, since 2018, a National project has been implemented to introduce a new model of nursing service; in 2020, the International Classifier of Nursing Practice Clinical Care Classification has been adopted but has not yet been approved at the national level.
Nursing Minimal Data Sets (NMDS) have been proposed to systematically describe nursing care. As early as 1988, Werley and Lang emphasized the need for minimal diabetes datasets that describe care in terms of nursing diagnosis, intervention, outcomes and nursing intensity. In 1991, Werley created the United States Minimum Data Sets on diabetes mellitus (US-NMDS). This was the first attempt to standardize the collection of core nursing care data to compare data on nursing care across populations, settings, geographic areas and time [11].
As the minimum data sets, checklists for various nosologies were developed for the nursing practice. One of the proposed forms "Nursing reception and nursing care during the initial visit of the patient to the out-patient department/filter with signs of SARS, including COVID-19" is currently implemented in the work of a mobile team and filters among nurses in order to reduce the burden on medical personnel. systematizing the work of nurses.
Based on the analysis of international experience, different countries have different approaches to maintaining nursing records. European countries learn from each other's experience by introducing minimal nursing data sets into the nursing process based on the Clinical Care Classification of the International Nursing Practice Classifier. Therefore, it is important in the process of reforming the nursing service in the Republic of Kazakhstan to introduce the Clinical Care Classification adapted to the conditions of the country's healthcare system.
Conclusion. Thus, the difficult situation with coronavirus infection in the world and Kazakhstan has led to the expansion of the functionality of nurses. The analysis made it possible to identify the nature of the epidemiological situation for coronavirus infection COVID-19, which served as the basis for the development of nursing documentation to improve preventive measures to combat coronavirus infection at the nursing process level.
Contribution of authors:
Smailova D.S. - scientific leadership, conceptualization, scientific support of the article, revision of the article.
Sydykova B.K. - analysis of statistical data.
Sarsenbayeva G.Z. - critical analysis, scientific support of the article.
Bolatov A.K. - analysis of international publications and article design.
Mussina G.A. - coding nursing diagnoses and interventions.
Baigozhina ZA. - scientific leadership, improvement of the article.
Khismetova Z.A. - critical analysis, scientific support of the article.
Funding: No outside funding was provided..
Publication details: No portion of this article has been published in other journals or is pending review by other publishers.
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Corresponding author:
Smailova Dariga Sansyzbaevna - PhD Doctor, NCJSC «Semey Medical University», Semey city, the Republic of Kazakhstan. Postal address: Republic of Kazakhstan, 071400, Semey, st. Abay 103. E-mail: [email protected] Phone: 8 705 555 84 68
