Local office network scheme. How to create clear logic (l3) network schemes. LAN design principles using computer programs

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1 Regional State Budgetary Establishment "Tomsk Basic Medical College" is considered and approved at a meeting of MDK "Therapeutic Business" N.I. Grechishnikova 2014. Nursing history of PM 02 disease "Participation in medical diagnostic and rehabilitation processes" MDC "Nursing Care with various diseases and conditions" Section 4 "Nursing Care with Infectious Diseases" in the specialty: "Nursing case" performed a student: Course of the Department Group: Nursing FULL NAME checked teacher Tomsk 2014 assessment.

2 Passport part Full name Patient Paul Age Personal Place of work, study, profession and position Date of registration in the hospital Department Subjective examination of the patient's complaint when the patient's complaint is received for the Church Day (in currently) A history of the disease when the disease began (date or age) from which the disease began (the causes, initial symptoms) how the disease was proceeded and its effectiveness (as often was the aggravation of chronic disease, where it was treated if the treatment was helped) 2

3 conducted studies (listed which methods of research were carried out by the patient) 1.Line diagnosis (patient complaints) Anamnesis Allergological history (note the presence of unusual reactions to food, medicines, animals, plants) epidanamnez: contact with patients with people and animals geographic history (where it from this area): social and domestic conditions (comfortable housing or not, the composition of the family The number of people in this area) food history (where it is powered by, which uses during the day) use in the noncompted form of water and milk hygienic The skills took the skills in the next 6 months of manipulation, operation, blood transfusion, the treatment of teeth anamnesis of life: where it was born, as grew and developed 3

4 transferred infectious diseases of the vaccination heredity (which the closest relatives suffer if they died from what) chronic foci of infection : The usual, disturbed, is missing (emphasize) the rumor: normal, reduced, no (emphasizes) Vision: Normal is broken, absent (emphasize) Consciousness: Clear, confused, missing (emphasizes) Position in bed: active, passive, forced (emphasize) Growing body weight BMI Temperature Build: normostic, hyperstenic, asthenic (emphasizes) Psychological status of the patient (availability of convulsion, excitement, delirium, hallucinations, memory, logic, statement of thought, sequence of reasoning) nervous system Sleep: Normal, Restless, insomnia (reason) Sleep duration Violation of gait breathing SIS Subject The form of the chest: the number of respiratory movements: breathing type: character of shortness of breath: expiratory, inspiratory, mixed presence of cough (dry, wet). The presence of sputum (purulent, serous, frothy, with blood). Presence of wheels: 4

5 Cardigo - Vascular Pulse System (synchronicity, Rhythmic, Frequency, Filling, Voltage) Hell on the right hand Hell on the left hand Condition of skin and mucous color (hyperemia, pallor, cyanosis, jaggility) Turgor, Edema's humidity Defects (scars) Limph System Inspection Lymphatic nodes (sizes, mobility, elasticity, sake) bone-muscular system Skeleton deformation (spinal curvature): Yes / No (emphasizes) Deformation of the joints: Yes / No. The volume of movements: muscles: the digestive system appetite: not changed, is reduced, absent, Increased, perverted (emphasizes) Features of nutrition: Swallowing: not difficult, difficulty (emphasizes) Teeth: Language: Zev (almonds, almonds, rear wall of the throat) Vomiting: Chair: consistency, smell, impurities, frequency of the abdomen: increase in volume: Ascitiya, methorism, ascites (emphasize) Participation of the abdomen in the act of breathing Yes / No urinary system Urination: free, difficult, painful, rapid 5

6 Watering: Color, Transparency, impurities Plan for care 1.Weight: 2. Diet: ATS, SHD, VBD, NBD, NKD (emphasize) Meal (Number times) independently or using (emphasize) Receiving fluid (number of times) Restriction Before performing movements. 3. Home needs of a person (violations emphasize) breathe, eat, drink, allocate, move, maintain their condition, maintain temperature, sleep, relax, dress, undress, be clean, avoid danger, communicate, work. Need 1. Normal breathing. Patient problem Map of the nursing process The goal of nursing intervention Plan of nursing interventions 2. Sufficient consumption of food and liquid. 3. Allocation of livelihoods from the body. 4. Movement and 6

7 Maintain the desired body position. 5. patient safety and its environment. 6. Maintaining body temperature 7. Rest and sleep. 8. Compliance with body hygiene, concern for appearance. 9. Ability and opportunity to actively communicate. 7.

8 10. Working work that brings satisfaction. Daily observation diary date, t 0, chdd, hell, Pus. Complaints, condition of consciousness and psyche, data of objective inspection on the day of the corporation manipulation of the care, mode, diet, the effect of treatment, tolerability of drugs 8

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2 Contents Page Passport Working Program of Curriculum 4 Results of the development of training practice 4 Structure and content of training practice 5 Terms of implementation of educational playback Control and evaluation of results

Introduction

Basic practice: State Regional Budget Healthcare Institution Old Russian Central District Hospital.

Practice goal: consolidate and deepen the knowledge gained in the learning process, acquire skills for all activities.

Practice Tasks:

To be able to conduct a patient survey, to carry out nursing diagnostics and care for the patient, own dependent, independent and interdependent sister interventions.

Be able to fill out the nursing diseases of the disease.

To be able to communicate with patients and their relatives, work colleagues and other medical team members.

I Implementation of the duties of a medical sister in the therapeutic department

Work in the therapeutic separation in the period of production

practices (pre-diploma) included

___________________________________________________________

___________________________________________________________

II Performance of the duties of a medical sister in the surgical department

Work in the surgical department during the period of production

practices (pre-diploma)

included _________________________________________

___________________________________________________________

___________________________________________________________

III Implementation of the duties of the medical sister in the pediatric department

Work in the pediatric department during the period of production

___________________________________________________________

___________________________________________________________

IV Nursing Patient Disease Story (Specify Branch)

Sample writing of the nursing history of a hospital therapeutic patient

Date and time of receipt _______________________________

Date and time of statement __________________________________

Office __________________ Chamber ____________________

Located in the department __________________________________

Conducted ____________________________________________

Types of transportation: on a notch, on the chair, can go (emphasize)

Blood group _______ Rhow-belonging _____________

Side effects of drugs ___________________________________________________

(drug title, side effect)

1. Surname, name, patronymic ____________________________________________________________________________________

2. Paul _________________

3. Age _________________________ (full years, for children: up to 1 year and month, up to 1 month - days)

4. Permanent residence: city, village (emphasize)

__________________________________________________________________

(Enter the address, specifying for visitors - area, district, us. Item, address of relatives and phone number)

5. Place of work, profession or position ____________________________

(for students - place of study; for children - name

__________________________________________________________________

children's institutions, schools; For disabled people and a group of disability)

6. The case is directed to the patient ___________________________________________________________

7. Directed in the hospital at emergency testimony: yes, no, through ______________________________________________________________

hours after the onset of the disease, injury: hospitalized in a planned order (emphasize)

8. Medical diagnosis ________________________________________________

9. Nursing diagnosis ________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________

1. Reason for treatment:

The opinion of the patient about his condition __________________________________________________

Expected Result___________________________________________________

2. Information source (emphasizes):

patient, Family, Medical Documents, Medpers, Dr. Sources

_____________________________________________________________

Patient opportunity to contact: yes no

Speech (emphasize): Normal, absent, broken

Vision: Normal, absent, reduced

Rumor: Normal, absent, reduced

3. Patient complaints: Currently _________________________________________________________

__________________________________________________________________

4. History of the disease:

12. When started

13. As started

14. How protected

15. Research conducted

16. Treatment, its effectiveness

5. Life story:

17. The conditions in which grew, developed (domestic conditions) ________________________________________________________

18. Working conditions, virtuality, Environment ________________

19. Transferred diseases, operations _____________________________

20. Gynecological history (beginning of menstruation _______, periodicity ______, soreness, abundance ___________, duration __________, last menstruation __________, pregnancy ___________, abortion ___________)

21. Allergological anamnesis:

food intolerance ________________________________________

drug intolerance ____________________________________

the intolerance to household chemicals _______________________________

22. Features of nutrition (which prefers) _________________________

23. Does the patient smoke (since how many years, how much per day _________________)

24. Alcohol attitude (emphasizes): Does not use, moderately, redundancy

25. Lifestyle (culture, belief, entertainment, rest, moral values) ____________________________________________________

26. Heredity (presence of blood relatives of the following diseases:

diabetes, high pressure, heart disease, stroke, obesity, tuberculosis, bleeding, anemia, allergic, cancer, diseases of the stomach, kidney disease, etc. ________________________________________________________

___________________________________________________________

6. An objective study (necessary to emphasize):

1. Consciousness: Clear, confused, missing

2. Behavior: adequate, inadequate

3. Mood: calm, sad, closed, angry, other _________________________________________________________

4. Position in bed: active, passive, forced

7. Temperature

8. Leather and mucous state condition: Turgor, humidity

color (hyperemia, pallor, cyanosis, jaggility)

defects (lying)

9. Power condition:

eveny yes no

hyperemia yes no

availability of raids yes no

10. Emission of soft tissues Yes No

before the middle of the neck

before the clavitry

below clavicle

11. The condition of lymph nodes:

painful yes no

squares with subject to fabrics yes no

changed leather over lymph nodes yes no

Bone-muscular system:

skeleton deformation (yes, no)

deformation of the joints (yes, no)

atrophy muscles (yes, no)

muscular power _____

leather in the joints of the joints (hyperemic) yes no

Respiratory system:

breath deep

rhythmic breathing

character shortness of shortness of breath (expiratory, inspiratory, mixed excursion)

tour of the chest

27. Symmetry

28. Cough (yes, no)

29. Mochotus (purulent, hemorrhagic, serous)

30. Smell (specific) (yes, no)

auscultation of the lungs:

31. Breathing: Vesicular, Hard

32. The friction noise of the pleura is no

33. Capital yes no

percussion of the chest:

34. The boundaries of the lungs are shifted _______________________

35. The presence of fluid yes no ____________________

The cardiovascular system:

pulse (frequency, voltage, rhythm, filling, symmetry)

pulse corresponds to 0 (yes, no)

Hell on two hands: left _________ right ___________

auscultation of the heart:

tones: Clear, muted, deaf

noise: availability, lack

Gastrointestinal tract:

appetite: Normal, reduced, lack

swallowing: Normal, difficult

removable teeth, prostheses (yes, no)

language covered (yes, no)

vomiting is associated with food (yes, no)

character of vomit (impurities: blood, mucus, ascites)

abundant, watery, meager (need to emphasize)

the presence of pathological impurities (mucus, pus, blood)

ordinary form

increased in volume: meteorism, ascites

assymmetric (yes, no)

palpation pain: in the epigastric region, throughout the stomach,

around the navel, in the iliac region, left, right

muscle tension

Urinary system:

urination: Normal, difficult, painful

frequent, broken, Anuria, the predominance of the daily over the night ___________________________________________

color of urine: normal, changed (hematuria, "meat oots", beer)

daily diuresis ______________

transparency

Endocrine system:

character of column: male, female

distribution of subcutaneous fatty fiber: male, female

visible increase in the thyroid gland (yes, no)

signs of acromegaly (yes, no)

eye symptom ______________________

exophthalm ___________________________

Nervous system:

sleep: Normal, Insomnia, Restless

tremor (yes, no)

gait violation (yes, no)

parey, paralysis (yes, no)

excited, inhibit (needed to emphasize)

Sociological examination:

lonely, family: number of children _______

Sex (reproductive system)

genitals (outdoor inspection)

milk glands: deformation

asymmetry (yes, no)

deformation (yes, no)

selection of nipple (yes, no)

Laboratory and Tool Research Plan

Nursing history.

Name of therapeutic and prophylactic institution: ____________________________

Department : Traumatology

receipt date 26.11.15 Extract Time: ______________________

I. Biographical data

FULL NAME. Puzankov Oleg Evgenievich
How to turn to the patient Oleg Evgenievich
Date of Birth 13.06.1970 (full years) 45
Floor male
Home address. Telephone. Moscow. Selotino, Sportivnaya Street, House 30, sq. 34
Family status. Married
The address and telephone of relatives, with whom you can contact if necessary (Full name, address, phone) Puzankova Tatyana Sergeevna (spouse) Selotino, Sportivnaya Street, house 30, sq. 34
Profession, position Senior Accountant
Social status : materially secured, works
Education Higher

II. Subjective data

1. The reason for entering the hospital: Acute pain in the right foot

2. Patient complaints for inspection day: Complaints of pain in the field of the right foot, temperature rise, weakness, malaise, fast fatigue.

3. Problems of the patient: ?????

History of this disease

1. considers himself to patients: He considers itself sick from 11/21/15, when during a fishing trip proportion foot sticking out of the ground.

2. What provokes deterioration: The movement of the damaged limb.

3. As affected the disease on the lifestyle of the patient:

4. What facilitates the state : (Tools used: drugs,

5. physical factors, etc.)

6. That the patient expects from staying in the hospital (from medical professionals): Waiting for recovery

The history of life

1. Transferred diseases: Rare colds, chickenpox tuberculosis, viral hepatitis denies.

2. Injuries, operations: Injuries, operations were not.

3. Risk factors for health: Smoking

4. Heredity: Heredity is not burdened.

5. Smoking (type of tobacco product, quantity, duration of use) Smoking cigarettes for ten years.

6. Alcohol use: Moderate

7. Environmental factors: Satisfactory.

8. Professional factors: Sedentary lifestyle.

9. Allergic history: Absent.

10. Living conditions: Satisfactory.

11. Hobbies, habitual leisure: Fishing, travel.

III. Objective examination

The physical state

Consciousness: Clear

Condition: Satisfactory

Position: inactive

Body type: Right

Power Status:

Height: 182 cm

Weight: 89 kg

Body temperature: 38,5

Leather and visible mucous membranes: Cleaning cleaning, pale

Skin appendages: Nails without features, hair clean

Peripheral lymph nodes: Not increased

Bone-muscular system: Turgor Normal

Respiratory system:

Breathing through nose In a calm state without a voltage separated from the nose.

The number of breathing: 20

Rhythm: Correct

Cough: Absent.

Last X-ray examination: On admission

Circulatory system system:

Pulse: 90 per minute, full, rhythmic, deficiency \u003d 0, symmetrical, satisfactory voltage

Arterial pressure:

On the left hand: 130 / 80mm RT. Art.

On the right hand: 135/85mm RT. Art.

Heart pain pain: no

Headache: not

Heartbeat: not

Dizziness: not

Numbness and feeling of tingling limbs: after this injury, the feeling of numbness, and pain in the right foot.

Digestive system:

Language: Language is not increased, moderately wet, covered with white raid.

Teeth: removable prostheses.

Swallowing : Not broken

Appetite : Not broken

Vomot : not

Chair : Diarrhea, without impurities

Cala's character: Liquid

Stomach: Conventional shape, painless with palpation

GOOD SYSTEM:

Urination : Free

Dysuric disorders: not

Endocrine system:

Inspection and palpation of the thyroid gland : not enlarged, no nodes

Distribution of subcutaneous fiber tissue: on male type

Nervous mental condition:

Emotional condition: Anxiety, depression

Orientation in the surrounding: not broken

Vision: wear glasses

Hearing: Not

Coordination of movements:

Sleep: Frequent, night awakening in recent times.

IV. Sheet of nursing observation

	Days of Curation
	1 day/	2 day /	3 day /
Priority Medical Problem on Courage Day		Survival of pain syndrome, antipyretic
Mode	Bed	Bed	Bed
Diet	Table number 5.	Table number 5.	Table number 5.
Hygiene (independently need help)	Assist is needed	Assist is needed	Assist is needed
Skin Covers (Coloring)	Clean	Clean	Clean
Consciousness	Clear	Clear	Clear
Pulse	90 per minute	85 per minute	87 per minute
HELL	130/80	125/70	125/80
Chadd
Body temperature	38,5	37,8	37,2
Appetite	Reduced	Reduced	Reduced
Chair	Diarrhea, without impurities	Diarrhea	Normal
Urination	Normal	Normal	Normal
Sleep	Sleeps in bed, needs day rest night Son: bad falls asleep, often wakes up (needs sleeping bag)	Intermittent	Normal
Complications when administering drugs (if any)	Absent	Absent	Absent

Map of nursing departure number 1 (chickening date).

Full name, patient age: Puzankov Oleg Evgenievich

Department: Traumatology

Medical diagnosis: __________

Nursing diagnosis: __________

Problem patient

Goal (Expected Result)

Actions of a medical sister

Periodicity, multiplicity

Summary assessment of the result

Real: Permanent pain in the right leg, sleep disorder, anxiety. Priority: High temperature potential: sepsis

Short-term: after the introduction of antibiotics, antipyretic and local antimicrobial drugs, the patient's condition will facilitate long-term: the patient will feel relieved state

Independent: provide physical and mental peace. Monitoring blood pressure and body temperature. Damaged limb bandage dependent: by appointment of a doctor:

Cefotaximi.

SOL. Analgini 50% - 2.0

SOL. Dimedroli 1% - 1.0

Interdependent:

Radiography
CT scan

Every day 2 times a day once in / in every day 2 times a day, per day 2 times a day upon admission, when discharged

The goal is achieved

Name of therapeutic institution: - GBUZ NSO BSMP № 2

Receipt date: 12.04.13

Department : Cardiology

Full name (patient): G.M. Floor: man

Age: 65 years old

Permanent residence: Novosibirsk city

Place of work, Profession, Position: pensioner

Emergency telephone: Available

Who sent: Polyclinic at the place of residence

Clinical diagnosis: Hypertensive view 3 of stage 2 degrees, IBS, hypertensive retinopathy, obesity of 2 degrees, proteinuria.

The development of the present disease (when it fell ill, with which it connects, as often exacerbates what is treated, with which the aggravation is currently):

Considers herself to be sick for 10 years, notes episodically emerging headaches, heaviness in the head, whiskest, especially in the morning, dizziness; Compressive pains for breasts and in the heart area, which are stopped at rest or after receiving 1-2 nitroglycerin tablets. Almost all the time, over the past two years, flickering flies in front of the eyes. Repeatedly received an ambulance compartment with hypertension, from where, after improving the condition, it was left independently, without having happened. She took papazole, but-shlu, nitroglycerin, was treated with herbs, biodevices. A year ago, somlements worsened, cristes became more frequent. In this regard, the patient appealed to the therapist and was hospitalized.

Intolerance to drugs, food, etc.: denies

Transferred diseases: Botkin's disease, tuberculosis, venereal diseases, diabetes, injuries, operations, other:

Among the suffering diseases, there are frequent acute respiratory diseases.

Patient complaints at the time of inspection:

Intensive headache, gravity in the field of the backbone, compressing pains for the sternum and in the heart, the feeling of the lack of air, dizziness, flickering of flies in front of the eyes, weakness.

Nursing diagnosis

1. True patient problems :
1.1. Priority
1. Intensive headache in the occipital and temporal areas;
2. Dyspun Inspiratory
3. Elevated blood pressure
4. Compressive pains for the sternum
5. Dizziness
1.2. The problems of the second plan
1. Nausea;
2. Intermittent sleep;
3. Reducing appetite;
4. No rational nutrition skills;
5. Increased sweating;
6. Fear for your health, concern about the future;
2. Potential problems :
1. High risk of stroke;
2. Hypertensive crisis;
3. Myocardial infarction;
4. Diseases of respiratory organs due to smoking;
5. Diseases of the cardiovascular system due to obesity.

Plan of nursing interventions on a priority problem

Problem: Intensive headache in the occipital and temporal areas

Purpose of nursing intervention:

Short-term goal: The patient will notice a reduction in headache intensity within a few hours of stay in the hospital;

Long-term goal: The patient will not prevent headache complaints by the time of extracting from the hospital.

Dependent nursing interventions:

1. Resern. Inside 0.10 mg. 1 p / day.
2. Winkon. Inside 0.01 g. 2p / day.

Interdependent intervention:

1. Common blood test;
2. Common urine analysis;
3. MRI brain.

Independent nursing interventions:

Medical sister will provide:

1. Therapeutic and security mode;
2. Fresh air access;
3. Bed comfort with a raised head end of bed;
4. Apply distracting agents: cold compress on the forehead, mustard pieces to the calf muscles;
5. Timely fulfillment of all appointments of the doctor;
6. In the appointment of the doctor will give an anesthetics;
7. Leisure patient after exiting acute state;
8. Preparation K. additional methods surveys;
9. The nurse will talk to relatives and neighbors on the chamber about the need to avoid tedious conversations;
10. The nurse will explain the patient the essence of his illness, will tell about modern methods of diagnosis, treatment and prevention.

The goal is achieved:

- the patient noted a decrease in headache intensity by the end of 1 day of stay in the hospital;
- the patient for the time of discharge from the hospital did not have complaints about the headache;

Dynamics of the development of patient problems

	Problem
		1. Provide fresh air access by venting out the chamber for 30 minutes 3-4 times a day; 2. Monitoring the patient's condition: control of blood pressure, pulse, chdd, appearance, well-being) 3. Mint drops to facilitate nausea seizures.
	Redued appetite	1. For 30-40 minutes toilet oral cavity, wipe the face and hands with a cool napkin; 2. Roaring room before bed; 3. Sheltered drink (cucumber brine, warm mineral water); 4. Feeding with small portions; 5. Conversations for distracted topics.
	Sleep disturbance	1. Carrying the chamber 15 minutes before sleep; 2. Creating full physical, psychological peace; 3. Provide clean, bed linen.
	Deficiency of knowledge of rational nutrition	1. In the process of the conversation, find out the taste needs of the patient, the power mode and the number of food consumed; 2. Find a patient with various species diet with reduced calorie; 3. Training the patient to make a menu for a week and consider calorie; 4. Weight control (1 time in 3 days); 5. Familiarize with various types of unloading days.
	Increased sweating	1. Change of linen as needed; 2. Compliance with the regimen; 3. Toilet skin (wiping with water-alcohol solution 2 times a day)

The nursing process in the clinic is a methodology for systematic professional care of patients who consistently conduct a qualified nurse. An integral part of this process is to create and fill the sister history of the patient's disease (medical history of the nurse).

During the nursing process, the base of the necessary patient data is created. It is identified by his needs for medical care, based on what is formed by the patient care plan and its implementation. In the course of therapeutic process and nursing care, in particular, the effectiveness of the selected plan is determined and whether the purpose of the patient's medical service has achieved. That is, first the patient has a survey and diagnosis, then the staff of the clinic that has medical services to the patient, plans the course of therapeutic process, then the plan is actually implemented in this case, and then the clinic staff assess the results obtained.

The final result of the nursing process becomes documented by the obtained data in the nursing history of the patient's disease.

What is the nursing history of the disease

Nursing Patient Disease History - this is actually a legal document that fixes an independent execution professional activity Nurses as part of its specialization. The main objective of the history of the nurse's disease is to control the work that the nurse holds, the demonstration of how it performs the treatment plan for the patient's care and recommendations of physician doctors, analysis of the quality of nursing assistance and the assessment of the professionalism of the nurse. Nursing disease history The patient filled with a nurse is a document that guarantees the quality and safety of medical assistance in the clinic.

Stages of filling the nursing history of the disease in the clinic

The first stage of filling in the nursing history of the patient's disease is to collect and design information about the current health of the patient who entered the clinic. The purpose of this stage is to find the relationship between the data obtained, which will help more accurately assess the patient's health at the time of his appeal to the doctor. Sources of data for the nursing history of the disease filled with a nurse in this case can be both the patient and members of his family or others, or employees of a medical professional brigade - if the patient was delivered to the ambulance. As a source of data for the history of the disease, nurses can perform a medical card or other medical docking of the patient - with its presence.

The patient's survey for the medical history of the nurse is carried out according to a specific scheme: first the nurse must clarify the passport details and other personal information of the patient (where and who he works, where he lives), then learn the patient's complaints and make their detail. The nurse collects anamnesis of the disease and conducts an objective examination of the patient. It makes all the information received in the nursing history of the patient's disease filled in the clinic. The appearance of the nursing history of the disease in each clinic can be its own designed specifically taking into account her work profile.

Fig. 1. Sample view of the nursing history of the disease filled with a nurse

Nuances of obtaining information for filling the sister history

The determination of what patient complains, gives the nurse an idea of \u200b\u200bthe problems of the patient. However, when polling the patient, the nurse must be remembered that it is not always able to clearly and clearly talk about his condition, so, asking questions to patients, the nurse must take into account his age and education. When surveys nurse, it is better not to ask patients with questions in the form, which provides either the answer "yes", or no answer, since this may eventually give a distorted impression about the true state of affairs.

To be mandatory to determine the data for the medical history of the nurse include the following:

the period of the beginning of the disease and what symptoms it began;
how sudden was the beginning;
how dynamically developed symptoms of the current disease and did not appear in the patient new symptoms;
as the patient felt immediately before a visit to the clinic.

In addition, it is necessary to ask the course of the disease for a long period of time - this may allow to emphasize the attention of doctors on potential patient problems.

IMPORTANT!
A significant stage of obtaining information about the patient for the history of the nurse's disease is to find out what studies a patient conducted, and what results of these studies were obtained. Also need the highest possible data on the treatment carried out earlier: which drugs were used, in which dosage, as they influenced the patient, and what was their tolerability.

Nurse When conducting a survey, you need to stably monitor the course of conversation with the patient with the help of leading questions, since patients often sharpen their attention to the details insignificant in this case.

When filling out the nursing history of the disease, it is required to take into account the history of the patient's life - from the period of childhood and school age before the start of work, and the diseases transferred to them. It is important and in what conditions the patient works, as it feeds on, what way of life prefers to lead, whether alcohol uses and in what quantities is alcohol, has an allergy to anything. In some cases, it is important to clarify what diseases of the patient's relatives were sick. The clarification of all these facts and the introduction of them in the nursing history of the disease, the nurse fill in the nurse can be important for recognition of diseases and the preparation of a plan for further treatment of the patient.

History of the nurse - Modern use practice

Svetlana Tikov, Home Medical Sister of Hospital JSC"Medicine" (Clinic Academician of Reutberg)

About company. Clinic of JSC "Medicine" - medical CenterSupporting patients with comprehensive high-tech medical care.

In our clinic, one of the basic functions of a medical sister is the accounting of medicines and the write-off of medicines in in electronic format in a special computer program clinic "Medical information system" Medical sisters write off drugs in a special section "Accounting and write-off of drugs". The whole story of writing is stored in our electronic form and is available to doctors.

It also would also like to pay attention to that the sheets of appointments and sheets of medical sisters of medical appointments are conducted only in electronic form. Of course, they are duplicated on paper media and are supported in the history of the patient's disease. Filling in the nursing history of the patient's disease is carried out in the form of so-called checklists.

Algorithm for receiving the transfer shift at the hospital medical post

The algorithm for receiving and transmitting a shift at the medical post: Medical sisters convey to each other a shift at the patient's condition. This is done at the patient's bed, so the check list is filled in manually, and in electronic form. The main positions that are considered is the identification of the patient is a generally accepted practice in our clinic.

Delivery nurse:

represents the patient a new medical sister who has replaced;
transmits a patient monitoring sheet;
makes a short oral report on a specific patient over the past day: reports briefly diagnosed, the main problems for the past day and what needs to be made from current affairs for the coming days, for example, some kind of diagnosis, some of the already designated tests, dressing, etc.

Nurses, transmitting and receiving, conduct a joint examination of the patient for the presence of some wound discontinued, physiological shipments, toilet, external view The patient, evaluate the patient's complaints, inspect the dressings, any drainage, catheters, intravenous, urinary, central, etc., if there are colostomas, then colostomas incl. Also carry out inspection of the chamber for the availability of all the necessary and efficiency of the equipment. This is mainly console, where gas flow, tonometers, if there is, glucometters, if the patient needs to monitor the glycemic profile during the day, etc.

instrumental research, etc. Transfer each other a sheet of appointments, the data on which is in the history of the nurse disease. If there are preparations that have changed over the previous period, then they voiced it too.

In a check list, the medical history of the nurse also reflects the additional forms of the nursing documentation necessary for filling:

the safety plan for patients of high risk of drops during the day, because in the dynamics throughout the period of the patient's patient's stay in the hospital, its condition may change. The state of gravity may change, so the risks of falls on our safety rules are tracked by medical sisters daily;
the pain schedule is tracked - the pain definition scale is from 1 to 10;
prevention of legs in heavy patients. If there is a breakdown, they are photographic and snapshots are attached to the check-lest in the history of the nurse's disease;
generally accepted temperature sheet;
hemodynamic indicators - pulse, breathing;
patient meals, if it has changed, it is also indicated in check lists;
poll patient, his wishes.

This is a detailed algorithm for receiving and transmitting shifts at a medical post in the hospital. Filling such a medical history by nurses is held daily. Check-sheet filling the patient's sister history of the patient's disease before surgery.

This algorithm for receiving and transferring shift at the medical record requires filling check-leaf and a anesthesiologist, and a medical sister. As a hospital nurse, which gives the patient, that is, sending it to the operating room, transports and a nurse who accepts. According to this filled check-line of the patient's sister history, a timeout is held, which also includes the patient's safety goal before the operation. It is necessary to identify the patient, checking the functioning of all equipment in the operating room: anesthetical apparatus, pulsaximeter, all surgical devices, implanted devices, etc.

The patient identification is carried out in the following way: surname, name, patronymic, year of birth, number of medical history of nurse. In the first identification to the anesthesia, the patient takes part in himself. After filling in this check-sheet of the patient's disease in the preoperative, scanning of the patient's bracelet, which contains information about it.

Thanks to this, we record the patient's filing time in the operating room, the identification of its data with the history of the nurse's disease and the diagnosis and the direction of operational intervention is carried out.

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Transcript.

What is the nursing history of the disease

Stages of filling the nursing history of the disease in the clinic

Nuances of obtaining information for filling the sister history

History of the nurse - Modern use practice

Algorithm for receiving the transfer shift at the hospital medical post

Last

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