Nursing history of the patient. Therapeutic medical history. Breathing is hard. Weakening of breathing on the left in the subscapular region. Moist fine bubbling rales and a slight pleural friction rub are also heard there.

Date and time of issue

branch Radiological ward № 8

Bed days spent

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

Side effects of drugs

__________________________________________________________________

(name of the drug, nature of side effects)

1. Full name Fifth Nina Alexandrovna.

2. Gender female.

3. Age (full years) 57 (13.02.1949) .

4. Permanent place of residence: city, village(emphasize)

Kinel-Cherkasy district, Kinel-Cherkassy, st. Sports, 26

(enter the address, indicating for travelers: region, district, settlement, address of relatives and telephone number)

5. Place of work, profession or position retiree.

(for students - the place of study, for the disabled - the type and group of disability, acting)

6. Who referred the patient ___________________________________________

through ___________ hours after the onset of the disease, injury;

hospitalized as planned (underline)

8. Medical diagnosis Malignant neoplasms pharynx

Stage I - subjective examination

1. Reason for contacting:

a) the patient's opinion about his condition I felt pain in my mouth. difficulty in swallowing.

b) expected result full recovery

2. Source of information (underline): patient, family, medical records, medical staff, other sources .

3. Patient's ability to communicate: Yes, No

Speech (underline): normal, violated, absent, violated

Vision: normal, reduced, missing

Hearing: normal, reduced, absent.

4. Complaints of the patient at the moment: weakness, burning in the mouth

5. When and how did you get sick: In December 2004 felt pain in the mouth, difficulty in swallowing turned to the ENT doctor who . sent for a consultation to the oncology dispensary.

6. Bad habits: denies.

Working conditions, occupational hazards __ until 2004 worked as a laboratory assistant in the oil field ___________ ________

Stage II - objective research

Physiological data (underline as appropriate):

1. Consciousness: clear, confused, missing.

2. Behavior: adequate, inadequate.

3. Mood (emotional state): calm, sad (th), closed (th), angry (th), etc. ______________ ________________

4. Sleep: normal, insomnia, restless _______________________

5. Position in bed: active, passive, forced.

6. Growth 162 cm

7. Weight 85 kg.

8. Temperature: according to the degree of rise _36.8 o C __________________________

by the nature of the temperature curve __normal ______

9. Condition of the skin and visible mucous membranes:

humidity moderate

Colour pale pink

the presence of edema missing

defects (pressure sores): localization __No __________________________

stage of development _____________________________

10. Breath:

frequency 20 per min

depth deep

rhythm rhythmic

The presence of shortness of breath(underline): yes No.

Having a cough(underline): yes no.

wet, dry.

11. Cardiovascular system:

Pulse: frequency 74 bpm

filling complete

voltage moderate

rhythm rhythmic

Blood pressure 130/ 80 mmHg Art. ..

12. Digestive system (underline):

appetite ( not changed, decreased, increased, absent)

swallowing ( normal, difficult)

chair ( framed constipation, diarrhea, incontinence).

13. Urinary system (underline):

urination ( free, difficult, painful, rapid)

urine color ( normal, changed - hematuria, "beer" color)

transparency: Yes, No.

localization _ in the pharynx ___________________________________

character __ cutting ________________________________ ____________

duration _when swallowing______________________________ _______

III - violation of the basic needs of the patient (underline):

breathe, there is, drink, highlight, move, maintain a state, keep the temperature sleep and rest, dress and undress, be clean, avoid danger, communicate, worship, work (play, study).

Name of the medical institution BMU KOKB

Date and time of receipt 03/01/2014 in 17.20.

branch tocardiology ward №5

Drug intolerance No

Past diseases: Botkin's disease, tuberculosis, sexually transmitted diseases, diabetes mellitus and others No

FULL NAME. Kozlov Nikolay Petrovich

Age 63 years old

Permanent residence: Kursk region, Kursk district, Anahino settlement, st. Lesnaya, 1

Place of work, profession, position retiree

Emergency phone tel. 26-45-01

Directed by polyclinic of the Kursk region

Clinical diagnosis Hypertonic disease, II stage

Student Grigorieva Irina Andreevna Group 3 m/s

II. Primary Nursing Examination Sheet

Complaints about headache in the occipital region, vomiting, dizziness, flies before the eyes.

subjective data

objective data

Patient problem

BREATH

Breathlessness: yes No

Cough: yes No

Phlegm: yes No

Is a special position required in bed:

Yes No

____________________________________________________________

Coloration of the skin and mucous membranes pale

Breathing rate 16 per min

Breathing depth medium depth

Breathing rhythm rhythmic

Dyspnea (expiratory, inspiratory, mixed)

Sputum (purulent, bloody, serous, frothy)

Smell: yes No

Pulse 92 in minutes; rhythmic arrhythmic

HELL 180 / 100 mmHg .

Pulse hard, tense

PROBLEM IDENTIFIED:

Tachycardia

Increased blood pressure (hypertension)

FOOD AND DRINK

Thirst: yes No

Appetite (retained increased downgraded is absent)

What does he prefer fried, fatty foods

Diet mistakes: Yes No

Dyspepsia (heartburn, belching, nausea, vomit)

Dry mouth: yes No

Ability to self-feed: Yes No

does not know about the diet with an increase in blood pressure

Diet No. 10

Growth 179 see Weight 85 kg

due weight 79 kg

Daily fluid intake 1000 ml

The nature of the vomit food eaten

Dentures: yes No

Chewing disorder: yes No

Swallowing disorder: yes No

Gastrostomy: yes No

___________________________________________________________________________

PROBLEM IDENTIFIED:

Decreased appetite

Lack of knowledge about rational nutrition, about diet

ALLOCATION

Stool frequency 1 time per day

The nature of the stool (liquid, decorated)

Pathological impurities No

Fecal incontinence: yes No

Urination (normal, painful, difficult, incontinence, incontinence)

Daily amount 700 ml

Wake up at night: yes No

Ability to use the toilet independently: Yes No

Sister's additions/remarks: _____________

Colostomy (ileostomy) No

Bloating: Yes No

The nature of the urine ordinary cloudy, the color of beer, meat slops)

Catheter No

_________________________

Cystostomy: yes No

_________________________

Edema: yes No

PROBLEM IDENTIFIED:

Not identified

Dream ( not violated, intermittent, rapid awakening, falling asleep in the morning, insomnia)

Bed comfort: Yes No ______________

Sister's additions/remarks: _____________

Sleep at night: Yes No

Daytime: yes No

_____________________________________________________________________________________________________________________________

PROBLEM IDENTIFIED:

Not identified

HYGIENE AND CHANGE

CLOTHES

Itching: yes No

Localization ________

Does he care about his appearance Yes

Ability to independently wash and comb hair, take care of the oral cavity, wash the whole body, change clothes Yes

Sister's additions/remarks: _____________

The condition of the skin and mucous membranes ( normal, dry, wet)

Color (regular, pallor, cyanosis, hyperemia, jaundice)

Turgor saved

bedsores No

Other defects (scratches, diaper rash) No

mucous membranes clean

Smell from the mouth: Yes No

Lingerie ( pure, dirty)

Sanitization ( complete, partial)

PROBLEM IDENTIFIED:

Not identified

MAINTENANCE

temperatureBODY

Chills: yes No

Feeling hot: yes No

Sister's additions/remarks: _____________

Body temperature 36,6 °C

____________________________________________________________________________________________________

PROBLEM IDENTIFIED:

Not identified

SECURITY

Risk factors:

Allergy No

Smoking I do not smoke

Alcohol (too much) No

Falls: yes No

Frequent stressful situations: yes No

Other No

Attitude towards illness calm

Ability to self-medicate there is

Need for Information available

Pain yes, headache in the occipital region

What gives relief taking antihypertensive drugs, reclining position

Sister's additions/remarks: does not consider this condition a disease

Orientation in time and space, self: Yes, no, there are episodes of disorientation No

Reserves: glasses, lenses, hearing aid, removable dentures, cane, etc. No

Ability to self-maintain your own safety: yes No

PROBLEM

DETECTED:

Headache in the occipital region Lack of knowledge about the disease, its complications and their prevention

MOTION

Moves independently: Yes, No

Moves with unaided

Goes to the toilet Yes No

Turns over in bed Yes No

Sister's additions/remarks: notes dizziness

Motor mode (general, ward, bed, strict bed)

position in bed active, passive, forced, special)

PROBLEM IDENTIFIED:

Dizziness

COMMUNICATION

Family status married

Family support: Yes No

Support outside the family relatives

Communication Difficulties No

Sister's additions/remarks: _____________

Consciousness clear

Speech ( normal, violated, absent)

Memory age appropriate

Vision ( normal, violated)

Rumor ( normal, lowered)

PROBLEM IDENTIFIED:

Not identified

REST AND WORK

Leisure agricultural work in the garden

Employability: yes No

Sister's additions/remarks : unable to work and rest due to headache and dizziness

PROBLEM IDENTIFIED:

Impaired performance and ability to rest

Disturbed Needs:

Highlight.

Avoid danger.

To be healthy.

Move.

Work.

Relax and socialize.

Patient problems:

Real:

Hypertension.

Vertigo, flashing flies before the eyes.

Tachycardia.
Decreased appetite.
Decreased work capacity.
Lack of knowledge about the disease, its complications and their prevention.
Lack of knowledge about diet.

Priority:

Headache in the occipital region associated with an increase in blood pressure.

Hypertension.

Potential:

Risk of deterioration.

High risk of complications (hypertensive crisis, visual impairment, acute myocardial infarction, cerebral stroke, acute renal failure).

Stavropol State

Medical Academy

Department of hospital surgery.

Head Department: Professor Vafin A.Z.

Group leader: Ph.D. Shigalov O.V.

MEDICAL HISTORY

Sarkisova Anaida Pavlovna

Curator - student of 510 A group

Slaykovskaya Olga Nikolaevna

Stavropol, 2006

general information

Full Name: Sarkisova Anaida Pavlovna

Age: 60 years old.

Female gender.

Higher education.

Marital status: Married.

Profession: Chemical engineer.

Place of work: Retired. Works at a private enterprise.

Home address: Stavropol, st. Burmistrova d. 9, apt. nine.

Date and time of admission to the hospital: 5 09.2006 10.00.

Hospitalization is emergency. Delivered by ambulance.

Clinical diagnosis: chronic calculous cholecystitis.

Concomitant diseases: No

Operation: Cholecystectomy 7 09 2006

Beginning of curation: 7 09 2006 0850.

7 09 2006 SUBJECTIVE RESEARCH

COMPLAINTS OF THE PATIENT

Minor pain in the right hypochondrium. Dry mouth.

COMPLAINTS ON AUTHORITIES AND SYSTEMS:

DIGESTIVE SYSTEM

Appetite: good. There is a bitter taste in the mouth in the morning.

Complaints about a feeling of heaviness in the epigastric region and in the right hypochondrium after eating fatty foods, sometimes accompanied by heartburn. Nausea after wrong diet.

Complaints of bloating. To reduce bloating, he takes espumizan. Stool: regular, tendency to diarrhea.

RESPIRATORY SYSTEM

Complaints of cough mainly in the morning, with a small amount of clear sputum.

BLOOD CIRCULATION ORGANS

Palpitation, stitching pains in the heart when excited. Pass on their own.

Periodic rises in blood pressure up to 140/90 mm Hg, which are manifested by headaches,. The condition improves after taking 20 mg of captopril.

Swelling of the legs in the evening, after walking.

URINARY ORGANS

No complaints

MOVEMENT BODIES

Complaints of pain in the knee joints after walking, fatigue.

NERVOUS SYSTEM AND SENSORS

Memory is normal. Vision is weakened (nearsightedness -1), hearing is normal.

FEVER

There was no fever prior to hospitalization.

HISTORY OF THE DEVELOPMENT OF THIS DISEASE

(medical history)

The disease began in 1987, when paroxysmal stabbing pains first appeared in the right hypochondrium after eating fatty foods. Ultrasound of the abdominal organs was performed, no pathology was detected. In the future, the disease slowly progressed, the attacks became more frequent up to 2 times a month. Antispasmodics were used to relieve pain, but without effect. I had to call an ambulance. Follows a diet.

On the evening of September 2, aching pain appeared in the right hypochondrium. The patient began to observe hunger. The pain didn't lessen. On the night of September 6, the pain became unbearable, paroxysmal. Called an ambulance in the morning. In the hospital, the attack was removed. Planned cholecystectomy on September 7, 2006.

LIFE HISTORY OF THE PATIENT

(anamnesis of life)

General autobiographical data: She was born in Baku. Mother was 25 years old, father 27. The first child in the family was a brother (5 years younger). She was born at term and breastfed. She grew and developed, keeping up with her peers, living and living conditions were good. At the age of 7 I went to school, finished 10 classes. Graduated from the Baku Institute. Married. Has 1 daughter. Pregnancies and childbirth (1982) were difficult. There was a lot of blood loss. Menopause began at 46 years old. Runs hard with "hot flashes", headaches. Work is currently associated with emotional stress.

Past illnesses: In childhood, frequent sore throats. At the age of 9 she suffered from scarlet fever. In 1971 she was operated on for acute appendicitis. Chronic obstructive bronchitis since 1996. The condition worsens in damp, cold weather. Notes periodic increases in blood pressure up to 140/90 mm. rt. Art. subjectively manifested by headaches, weakness. She does not use any medication regularly.

Allergic reactions do not mark Alcohol does not use, does not smoke. She denies tuberculosis, sexually transmitted diseases in herself and her immediate family.

Family history: Daughter is healthy. Parents died at the age of over 80 years. My aunt and father had diabetes. My brother died during an operation for bowel cancer. No other hereditary diseases noted.

OBJECTIVE STUDY OF THE PATIENT

GENERAL INSPECTION

The patient's condition: Satisfactory.

Consciousness: clear.

Position of the patient: Active.

Facial expression: calm.

Body type: correct.

Constitutional type: normosthenic.

Height 160 cm. Weight 86 kg.

Skin: Normal color, normal humidity. Skin turgor is moderately reduced. Hair on the female type.

Sclera of normal color, not changed.

The subcutaneous tissue is moderately developed, there are no edema.

Lymph nodes: sublingual, submandibular anterior cervical and posterior cervical, parotid, occipital, supra and subclavian, intercostal, axillary, ulnar, inguinal, popliteal are not palpable.

Muscles: developed normally. Bones: No deformities. There is no pain on palpation. Joints: not changed, movements in full.

The thyroid gland is not enlarged.

RESPIRATORY SYSTEM

Examination of the chest: the form is normosthenic, the epigastric angle is close to a straight line; both halves of the chest participate in the act of breathing in concert. The supraclavicular and subclavian regions are normal, the scapulae are tightly pressed against the ribs, symmetrical, no curvature of the spine was found.

Type of breathing: abdominal, The depth of breathing is normal, breathing is rhythmic. The number of breaths per minute: 19. There is no shortness of breath at rest.

Palpation of the chest: no pain on palpation, the chest is elastic. Voice trembling is not changed. Lung percussion: With comparative percussion over the entire surface of the lungs, a clear pulmonary sound is determined. The width of the Krenig fields: 5 cm. The height of the tops in front: 3 cm, behind: at the level of the spinous process of the VII cervical vertebra.

Location of the lower borders of the lungs:

	Right	Left
Linea parasternalis	5th intercostal space
Linea medioclavicularis
Linea axillaries anterior
Linea axillaries media
Linea axillaries posterior
Linea scapularis
Linea paravertebralis		Spinous process of XI thoracic vertebra

Mobility of the lower edges of the lungs:


	On exhalation	Total	On exhalation	Total
Linea axillaries media

Lung auscultation: vesicular breathing, no wheezing.

BLOOD CIRCULATION ORGANS

Examination of the arteries and veins Arterial pulse on the radial arteries is rhythmic and the same on both arms. Frequency 68 beats per minute. Pulse of good filling and tension. There is no pulse deficit. There are no murmurs over the arteries. There is no capillary pulse. Blood pressure: 120/80 mm Hg Neck veins, veins of the anterior abdominal wall are not dilated.

Examination and palpation of the heart area: there are no protrusions in the heart area. The apical impulse in the 5th intercostal space is 1 cm medially from the left midclavicular line, limited, of normal height, strength and resistance. There is no heartbeat. The area is painless on palpation.

Percussion of the heart: limits of relative cardiac dullness:

1. right - in the 4th intercostal space along the right edge of the sternum

2. left - in the 5th intercostal space 1 cm medially from the left mid-clavicular line.

3. top - in the 3rd intercostal space ..

the configuration is normal, the diameter is -10 cm, the width of the vascular bundle in the 2nd intercostal space is 4 cm

Auscultation of the heart:

1 point. 2 tones are heard (preferably the first one), rhythmic, clear, no noise.

2 point. 2 tones are heard (better than the second one), the tones are rhythmic, clear, there is no noise.

3 point. 2 tones are heard (better than the second one), the tones are rhythmic, clear, there is no noise.

4 point. 2 tones are heard (preferably the first one), the tones are rhythmic, clear, there are no noises.

5 point. 2 tones are heard, rhythmic tones, clear, no noise.

DIGESTIVE ORGANS

Examination of the oral cavity: there is no smell from the mouth. The tongue is moist and clean. No teeth, dentures. Zev normal color.

Inspection of the abdomen: regular shape, soft, rounded shape, symmetrical. The abdomen is enlarged due to subcutaneous fat. In the right iliac region, a postoperative scar in an oblique direction, about 8 cm long, about 0.8 cm wide, rises above the skin surface.

Superficial palpation: The abdomen is painless on superficial palpation. There is no divergence of the abdominal muscles along the white line. Shchetkin-Blumberg's symptom is negative.

Methodical deep, sliding, topographic palpation according to the Obraztsov-Strazhesko method: With deep palpation, a large curvature of the stomach could not be determined. The transverse colon, ascending and descending sections of the colon are painless on palpation. They are palpated as smooth elastic cylinders, there are no seals. The sigmoid colon, palpable in the left iliac region, 2 cm wide, slightly painful, elastic, mobile. On palpation, rumbling. The caecum is palpable in the right iliac region, elastic, tense, smooth, 2 cm in diameter. Painless on palpation.

Percussion of the abdomen: the nature of the percussion sound is tympanic. Free fluid in the abdominal cavity is not determined.

Auscultation: peristaltic sounds are heard.

LIVER, GALL BLADDER, SPLEEN.

Liver examination: Percussion of the liver according to Kurlov

1. On the right mid-clavicular line, the upper border is the 5th intercostal space, the lower one is along the costal arch (size 9 cm.)

2. On the midline: size 8 cm.

3. On the left costal edge: size 7cm.

Palpation of the liver: the edge of the liver is rounded, smooth, painless; the surface is smooth.

Spleen: it was not possible to palpate and percuss.

URINARY SYSTEM

The kidneys could not be palpated. The ureteral points are painless. The effleurage symptom is negative on both sides.

LOCAL EXAMINATION OF THE PATIENT

local status

Abdomen of correct configuration, not swollen. The anterior abdominal wall evenly participates in the act of breathing.

The abdomen is painless on superficial palpation. There is no divergence of the abdominal muscles along the white line. Shchetkin-Blumberg's symptom is negative.

The gallbladder is not palpable, palpation at the Kera point is painful; Ortner's sign is positive.

Tapping symptom is negative on both sides

DATA FROM ADDITIONAL STUDIES

Laboratory

General blood analysis 6 09.2006

Hemoglobin 132 g/l

Leukocytes 4.7x10 9

ESR 10 mm/h

Neutrophils Lymphocytes Monocytes Eosinophils

6 09.2006 - Microreaction for syphilis - negative

6 09.05 - Blood chemistry.

Bilirubin total 13.0 µmol/l

indirect 13.0 µmol/l

direct 0 µmol/l

AST 17 U/l

ALT 18 U/l

Urea 4.8 mmol/l

Creatinine 70 µmol/l

Total protein 68 g/l

Glucose 4.79 mmol/l

Analysis of urine : 7 09.06

Color - straw yellow.

Specific gravity - 1016.

The reaction is acidic.

Protein not found.

Renal epithelium 1

flat 7

yeast spores

Instrumental Research

ECG 7 09 2006 Conclusion: The rhythm is sinus. Semi-horizontal electrical position of the heart.

Ultrasound of the abdominal organs. 6 09 2006.

Liver right lobe 138 mm Left lobe 87 mm, smooth edge. The echostructure is diffusely heterogeneous. Intrahepatic duct without features.

The gallbladder is enlarged 89*44 mm, wall thickness 6 mm, compacted. The echogenicity of the gallbladder is increased. In the area of the neck there is a calculus with a diameter of 40 mm.

The pancreas is not enlarged. The contour is clear and even. The structure is diffusely heterogeneous, echogenicity is increased.

Conclusion: Echo-signs of cholelithiasis.

PRELIMINARY DIAGNOSIS

Based on complaints: pain in the right hypochondrium. Bitter taste in the mouth. Anamnesis pain in the gallbladder, frequent attacks. Palpation data: expansion of the umbilical ring up to 3 cm. soreness at the Kera point; Ortner's sign is positive. Instrumental research data:- Conclusion. Ultrasound of the abdominal organs Echo-signs of cholelithiasis. Delivered provisional diagnosis: Chronic calculous cholecystitis.

DIFFERENTIAL DIAGNOSIS

Differential diagnosis should be carried out with the following diseases: gastric / duodenal ulcer, right-sided renal colic.

	Acute cholecystitis	Acute appendicitis	peptic ulcer	Renal colic
The nature of the pain	In the right hypochondrium, strong, paroxysmal, then constant, irradiation to the right shoulder blade, shoulder girdle	In the epigastrium, moderate intensity, then move to the right iliac region, pulling, constant	In the epigastric region, of varying intensity, associated with food intake, stopped by taking antacids	In the lower back, paroxysmal, extremely intense with irradiation in the groin, reduced by the use of antispasmodics
Other complaints	Nausea, vomiting without relief	Nausea, vomiting, stool retention, fever	Dyspeptic symptoms	Possible dysuria
	Cholelithiasis		peptic ulcer	Urolithiasis disease
Development	Usually subacute		More often chronic
Objective examination	Soreness and muscle tension in the right hypochondrium, symptoms of Ortner, Murphy, Mussy, Mayo-Robson, Mendel in the right hypochondrium, moderate intoxication	Soreness and muscle tension in the right iliac region, peritoneal irritation, Voskresensky, Razdolsky, Obraztsov, Rovsing, Sitkovsky, marked intoxication	Minimal changes: there may be pain on palpation in the epigastrium, there is no intoxication	Abdominal palpation is usually painless, positive Pasternatsky s-m, no intoxication
Additional examination	Ultrasound, Inflammatory changes in the general blood test	Changes in the general blood test, indicating inflammation	More often without features	Erythrocyturia

CLINICAL DIAGNOSIS

Chronic calculous cholecystitis.

PREOPERATIVE DIARY

7 09 2006 The patient's condition is satisfactory. Complaints of aching pain in the right hypochondrium. Respiration is vesicular. Heart sounds are clear, rhythmic. The abdomen is soft, moderate pain at the Kera point. BP 120/80 mm Hg. Pulse 70 beats per minute. The patient was prepared for the operation - fasting was prescribed, cleansing enemas were performed, the surgical field was shaved, the lower limbs were bandaged with an elastic bandage.

JUSTIFICATION OF THE OPERATION

The presence of chronic calculous cholecystitis with frequent attacks that are not stopped by medication is an indication for planned cholecystectomy. The patient's consent to the operation was obtained.

PREPARATION FOR OPERATION

On the eve of the operation, the patient was given cleansing enemas, the patient took a shower, the surgical field was shaved, the lower limbs were bandaged with an elastic bandage. On the day of the operation, hunger was prescribed.

Premedication:

Amoxyclav 1.2 iv, Promedoli 2%-1.0 IM Dimedroli 1%-1.0 IM, Atropini 0.1%-0.5 IM.

OPERATION DESCRIPTION

Cholecystectomy.07 09 2006 12:00-14:00

Upper-middle laparotomy was performed under endotracheal anesthesia. The gallbladder is in adhesions, entangled with an omentum, tense and edematous. In the lumen is a calculus up to 4 cm in diameter. Cholecystectomy with ligation of the cystic artery and cystic duct stump and suturing of the liver bed. The subhepatic space was drained with a PVC tube. Hemostasis. Layer-by-layer seams on the wound, with summing up the subcutaneous fat of the rubber strip. Aseptic bandage.

Preparation: Gallbladder chronic cholecystitis 10*8*0.5 was sent for histological examination.

POSTOPERATIVE DIARY.

14.00 - The patient was delivered from the operating room on a ventilator - Ambu bag. She was transferred to a ventilator with a FAZA-5 device with gas ventilation parameters. Skin without features. Auscultatory breathing is carried out in all parts of the lungs. Abdomen without features. BP 130/80 mm Hg Pulse 80 beats per minute

17.00 - Against the background of the restoration of muscle tone after sanitation of the TBA and the oral cavity, the patient was extubated.

20.00 8 09 2006- Transferred from OITAR The patient's condition is satisfactory. Complaints of moderate pain in the area of the postoperative wound, bitterness in the mouth. Respiration is vesicular. Heart sounds are clear, rhythmic. Tongue wet, lined with white coating. The abdomen is soft and moderately painful in the area of the surgical wound. Peristalsis is sluggish. The area of the postoperative wound is hyperemic and edematous. A small amount of serous-hemorrhagic discharge was released along the drainage. BP 120/80 mm Hg Pulse 69 beats per minute. Urine is released by a catheter. Diuresis is adequate.

9 09 .2006 - The patient's condition is moderate. Complaints of moderate pain in the area of the postoperative wound, bloating, cough. Vesicular breathing on the left below the angle of the scapula, single dry scattered rales are heard, disappear when coughing. Heart sounds are clear, rhythmic. The tongue is moist, lined with white coating. The abdomen is soft and moderately painful in the area of the surgical wound. The wound is in a satisfactory condition. Serous-hemorrhagic discharge from the wound, swelling and hyperemia decreased. The bandage was changed BP 110/80 mm Hg. Pulse 71 beats per minute. There is no chair. The patient was given a gas outlet tube.

11 09 2006 - The patient's condition is moderate. Complaints of moderate pain in the area of the postoperative wound, cough. Breathing is vesicular, rales are not heard. Heart sounds are clear, rhythmic. The tongue is moist, lined with white coating. The abdomen is soft and moderately painful in the area of the surgical wound. The wound is in a satisfactory condition. A small amount of discharge from the wound. No infiltrate was found in the area of the postoperative wound. Bandage change BP 120/80 mm Hg. Pulse 68 beats per minute.

12 09 .2006 - The patient's condition is satisfactory. There are no complaints. Respiration is vesicular. Heart sounds are clear, rhythmic. The tongue is moist, lined with white coating. The abdomen is soft and moderately painful in the area of the surgical wound. The wound is in a satisfactory condition, heals by primary intention. No infiltrate was found in the area of the postoperative wound. There is no separable. The drain has been removed. Bandage change BP 120/80 mm Hg. Pulse 62 beats per minute.

TREATMENT

Dimedrol 1.0-1% IM at 2200

Ketorol 1.0 IM 3 times a day.

Amoxiclav 1 tab 3 r a day

Prozerin 0.06% -2.0 s / c 2 r per day

Physiological solution 200 ml + CS! 4% -1.0

EPICRISIS

The patient, Sarkisova Anaida Pavlovna, 60 years old, was admitted to the surgical department of the Regional Clinical Hospital on September 6, 2006 at 10 00 due to an acute attack of cholecystitis. The attack is stopped. Cholecystectomy was performed on September 7, 2006, 2006 under endotracheal anesthesia. The postoperative period proceeded without complications. The patient was prescribed treatment, appropriate recommendations were given.

The release is planned for the next few days.

FORECAST

The prognosis for life is favorable, recovery. Full recovery.

The nursing process in a clinic is a method of systematic professional care for patients, which is consistently carried out by a qualified nurse. An integral part of this process is the creation and completion of the patient's nursing record (nurse record).

During the nursing process, a database of necessary data about the patient is created. His needs for medical care are identified, on the basis of which a patient care plan and its implementation are formed. In the course of the medical process and nursing care, in particular, the effectiveness of the chosen plan and whether the patient's medical care has reached the goal is determined. That is, first the patient undergoes examination and diagnosis, then the clinic staff providing medical services to the patient plans the course of the treatment process, then the plan adopted in this case is actually implemented, and after that the clinic staff evaluates the results.

The end result of the nursing process is the documentation of findings in the patient's nursing history.

What is a nursing history

The patient's nursing history is actually a legal document that records the independent performance of the nurse's professional activities within the framework of her specialization. The main purpose of the nurse's medical history is to monitor the work that the nurse does, demonstrate how she carries out the treatment plan in the field of patient care and the recommendations of doctors in the treatment process, analyze the quality of nursing care and evaluate the professionalism of the nurse. sisterly medical history patient, completed by a nurse - a document that guarantees the quality and safety of medical care in the clinic.

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

The first step in filling in the patient's nursing history is the collection and registration of information about the current state of health of the patient admitted to the clinic. The purpose of this stage is to find the relationship between the data obtained, which will help to more accurately assess the patient's state of health at the time of his visit to the doctor. In this case, the sources of data for the nursing history filled in by the nurse can be both the patient himself and his family members or those around him, or members of the medical care team - if the patient was taken by ambulance. The medical record or other medical documentation of the patient, if available, can serve as a source of data for the nurse's medical history.

The patient is interviewed for the medical history of the nurse according to a certain scheme: first, the nurse must clarify the passport data and other personal information of the patient (where and by whom he works, where he lives), then find out the patient's complaints and detail them. The nurse collects an anamnesis of the disease and conducts an objective examination of the patient. She enters all the information received into the patient's nursing history, which is filled in the clinic. The appearance of the nursing history of each clinic can be different, designed specifically for the profile of her work.

Rice. 1. Sample view of a nursing history completed by a nurse

The nuances of obtaining information for filling out a nursing history of the disease

Determining what the patient is complaining about gives the nurse an idea of the patient's problems. However, when interviewing a patient, the nurse needs to remember that he is not always able to clearly and distinctly tell about his condition, therefore, when asking questions to patients, the nurse must take into account his age and education. In interviews, it is better for a nurse to avoid asking patients questions in a form that provides either a “yes” or “no” answer, as this may ultimately give a distorted impression of the true state of affairs.

Required data for the nurse's medical history include the following:

the period of onset of the disease and the symptoms with which it began;
how sudden the onset was;
how dynamically the symptoms of the current disease developed and whether the patient developed new symptoms;
how the patient felt immediately before the visit to the clinic.

In addition, it is necessary to take an interest in the course of the disease over a long period of time - this may allow doctors to focus on the potential problems of the patient.

IMPORTANT!
A significant step in obtaining information about the patient for the nurse's medical history is to find out what studies the patient has performed and what results of these studies have been obtained. We also need as much data as possible about the previous treatment: what drugs were used, at what dosage, how they affected the patient, and what was their tolerability.

When conducting a survey, a nurse needs to stably control the course of a conversation with a patient with the help of leading questions, since patients often focus their attention on details that are insignificant in this case.

When filling out a nursing history of the disease, it is required to take into account the patient's life history - from the period of childhood and school age to the start of work - and the diseases he has suffered. It is also important in what conditions the patient works, how he eats, what lifestyle he prefers to lead, whether he smokes and in what quantities he drinks alcohol, whether he is allergic to anything. In some cases, it is important to clarify what diseases the patient's relatives had. Finding out all these facts and entering them into the nursing history filled by the nurse can be important for recognizing illnesses and drawing up a plan for further treatment of the patient.

Nurse's medical history - current practice of use

Svetlana Tipkova, chief nurse of the AO hospital"Medicine" (clinic of Academician Roitberg)

About company. Clinic JSC "Medicina" - a medical center that provides patients with comprehensive high-tech medical care.

In our clinic, one of the main functions of a nurse is accounting for medicines and writing off medicines in electronic form in a special computer program of the clinic "Medical Information System". Nurses write off medicines in a special section “Accounting and writing off medicines”. The entire write-off history is stored electronically and is available to doctors.

I would also like to draw your attention to the fact that the lists of appointments and sheets for the fulfillment of medical appointments by nurses are kept only in electronic form. Of course, they are duplicated on paper and backed up in the patient's medical history. Filling in the patient's nursing history is carried out in the form of so-called checklists.

Algorithm for receiving transfers of shifts at a medical post in a hospital

The algorithm for receiving and transferring shifts at a medical post is as follows: nurses transfer shifts to each other according to the patient's condition. This is done at the patient's bedside, so the checklist is filled out both manually and electronically. The main positions that are considered are the identification of the patient - this is a common practice in our clinic.

Passing Nurse:

introduces to the patient a new nurse who has come to replace;
submits a patient observation sheet;
makes a short oral report on a specific patient over the past day: briefly reports his diagnosis, the main problems over the past day and what needs to be done from current affairs for the coming day, for example, some kind of diagnosis, some already prescribed tests, dressings, etc.

The nurses transmitting and receiving conduct a joint examination of the patient for the presence of any wound discharge, physiological discharges, toilet, patient's appearance, evaluate the patient's complaints, examine bandages, any drains, catheters, intravenous, urinary, central, etc. if there are colostomies, then colostomies incl. They also conduct an inspection of the ward for the presence of all necessary and operability of equipment. These are mainly consoles where gases are supplied, tonometers, if any, glucometers, if the patient needs to monitor the glycemic profile during the day, etc.

instrumental studies, etc. They pass each other a sheet of appointments, the data on which is in the nurse's medical history. If there are drugs that have changed over the previous period, they also voice this.

The nurse's medical record checklist also reflects additional forms of nursing documentation required to complete:

a safety plan for patients at high risk of falls during the day, because in dynamics throughout the entire period of the patient's stay in the hospital, his condition may change. The state of severity can change, so the risks of falling according to our safety rules are monitored by nurses on a daily basis;
a pain graph is monitored - a scale for determining pain according to VAS from 1 to 10;
prevention of bedsores in critically ill patients. If bedsores occur, they are photo-documented and the pictures are attached to the checklist in the nurse's medical history;
generally accepted temperature sheet;
hemodynamic parameters - pulse, respiration;
the patient's nutrition, if it has changed, this is also indicated in the checklists;
questioning the patient, his wishes.

This is a detailed algorithm for receiving and transferring shifts at a medical post in a hospital. The filling of such a medical history by nurses is carried out daily. Checklist for completing the patient's nursing history before surgery.

This algorithm for receiving and transferring shifts at a medical post requires filling out a checklist by both an anesthesiologist and a nurse. As a hospital nurse who delivers a patient, that is, sends him to the operating room, transports, so does a nurse who receives. According to this completed checklist of the patient's nursing history, a time-out is carried out, which we also include in the patient's safety goals before the operation. It is mandatory to identify the patient, check the functioning of all equipment in the operating room: anesthesia machine, pulse oximeter, all surgical devices, implantable devices, etc.

Patient identification is carried out as follows: last name, first name, patronymic, year of birth, nurse's medical record number. The patient himself takes part in the first identification before anesthesia. After filling in this checklist of the patient's medical history, the patient's bracelet is scanned in the preoperative room, on which information about him is stored.

Thanks to this, we fix the time of the patient's arrival in the operating room, verify his identification with the nurse's medical history and diagnosis, and refer him for surgery.

Educational Nursing Medical History

Medical card No. 4335 of an inpatient

Date and time of admission: 05/22/10 13:20

Department: children's department, ward No. 8

Full name: XXX (25.09.09)

Female gender

Age: 8 months

Place of residence: Slavyansk-on-Kuban, st. Sportivnaya, 3, apt. 27

Parents: mother: XXX, aged 24, JSC Kuban energy supply, engineer.

Father: XXX 24, Azov Chernomor, financial manager.

Who referred the patient: ambulance

Diagnosis of the referring institution: ARVI

Diagnosis at admission: SARS

Clinical diagnosis: SARS

Medical history

Date: 22/V Time: 13:20

Complaints: temperature rise to 38.9°C, dry cough, sick for 2 days.

Child from 1 pregnancy, 1 birth. The pregnancy proceeded without complications. The course of labor is urgent.

Baby's weight at birth: 3675 g, length: 54 cm, Apgar score 5/7. discharged from the hospital on the 5th day with a weight of 3650 g. The remainder of the umbilical cord fell off on the 3rd day. It was applied to the chest on the 3rd day. The neonatal period proceeded without complications.

Feeding a child: breastfed up to the 1st month.

The diet is age appropriate.

Living conditions are satisfactory. Mode, walks and meals are age appropriate. The child's behavior is calm.

Allergic history: skin rash from cow's milk.

epidemiological history. She has not gone anywhere outside the region for the last 3 weeks, she has not communicated with infectious patients.

Dynamics of physical and psychomotor development

He holds his head from 2 months, sits from 6 months, does not walk. Walking since 3 months.

Currently: weight - 9400 g, height - 70 cm, head circumference - 43.5 cm, chest circumference - 43 cm. Physical and psychomotor development corresponds to age norms.

Information about preventive vaccinations:

Vaccination dates match.

Hepatitis B

Polio

The general condition is of moderate severity, the position is active, the behavior is normal.

Consciousness is clear.

Weight - 9400 g, height - 70 cm, head circumference - 43.5 cm, chest circumference - 43 cm, temperature - 38.9°C.

The skin is clean, normal color.

Visible mucous membranes are moist.

In the pharynx - hyperemia of the posterior pharyngeal wall.

Subcutaneous fat is developed satisfactorily.

There are no edema.

Lymph nodes - not enlarged, painless on palpation.

Muscles: well developed, normal tone, painless on palpation.

Joints and bones: not changed, movements are free, painless.

Respiratory system

Breathing is rhythmic, respiratory rate is 28/min. Breathing through the nose is difficult, the chest is of a normal shape.

Circulatory system

Pulse - 128/min., rhythmic. Pulsations and bulging of the cervical veins are not observed.

Digestive system

Appetite is normal, acts of chewing, swallowing and passage of food through the esophagus are not disturbed. Belching, heartburn, vomiting - no. The back wall of the pharynx is hyperemic. The shape of the abdomen is normal. On palpation of the abdomen - the abdomen is soft, painless. Diarrhea - no. Sometimes there are constipations.

urinary system

Urination free, painless, frequent. The color of urine is straw yellow. There is no swelling, redness in the projection area of the kidneys.

Nervous system and sense organs

Hearing and vision impairments were not found. Sweating is moderate. The condition of the hairline is normal.

Laboratory research

UAC + sea from 05/23/10

OAM from 23.05.10

Mor - neg.

Erythrocytes - 3.4 T/l Reaction - neutral

Hb - 100g/g weight - 1010

Leukocytes - 3.8 g/l Protein - neg.

ESR - 3 mm Sugar - neg.

Epithel. class - single

Leukocytes - 1-2 in the field of view

Cal on i/g + capprogram dated 24.05.10

Cal - yellow-green color, decorated, soft.

i/g - not found.

A swab from the throat and nose dated 05/23/10.

Tsifobol - feelings.

Cefotaxime is stable.

Pharmacotherapy

Suprastin (solution for injection):

Indications:

hives,

angioedema (Quincke's edema),

serum sickness,

seasonal and perennial allergic rhinitis,

conjunctivitis,

contact dermatitis,

skin itch,

acute and chronic eczema,

atopic dermatitis,

food and drug allergies,

allergic reactions to insect bites.

Contraindications:

hypersensitivity to the components of the drug,

acute attack of bronchial asthma,

newborn babies (term and premature),

pregnancy,

lactation period.

With caution: angle-closure glaucoma, urinary retention, impaired liver and kidney function, cardiovascular disease, elderly patients.

Analgin (Analginum):

Indications: pain syndrome of various origins (headache, migraine, toothache, neuralgia, postoperative pain, fever in infectious and inflammatory diseases.

Contraindications:

hypersensitivity to pyrazolone derivatives,

tendency to bronchospasm,

severe disorders of the liver and kidneys,

blood diseases.

Cefantral (Cefotaxime):

Indications:

Severe bacterial infections caused by susceptible microorganisms:

CNS infections (meningitis),

lower respiratory tract and ENT organs,

urinary tract,

joints,

skin and soft tissues,

pelvic organs,

infected wounds and burns

peritonitis,

endocarditis,

prevention of infections after surgery,

Contraindications:

hypersensitivity to cephalosporin antibiotics (including penicillins, carbapenems), in children under 2.5 years of age, intramuscular administration of the drug.

With caution: in the neonatal period, during pregnancy and lactation, in patients with impaired renal and hepatic function, with ulcerative colitis (including history).

Discharge summary

Full name: XXX
Age: 8 months.
Received with complaints: on the rise in body temperature up to 38 °,
On examination: a state of moderate severity, impaired health.

Examination carried out:

KLA +mor: (Mor - neg., Erythrocytes - 3.4 T / l, Hb - 100g / g, Leukocytes - 3.8 g / l, ESR - 3 mm).

OAM: (Specific weight - 1010, Protein - neg., Sugar - neg., Epithelial cells - single, leukocytes - 1-2 in the field of view).

Feces on i/g: (i/g not detected).

Throat and nose swab:

Sensitivity to antibiotics:

Tsifobol - feelings.

Cefotaxime is stable.

Treatment carried out:

Cifobol 350 thousand x 3 r

Suprastin 0.3

Analgin 50% -0.2

Cefotaxime 300 thousand x 3 r

It is useful during illness, and in the first weeks of recovery, to give the child multivitamins, especially vitamin C. Primary prevention includes rational feeding, sufficient exposure to fresh air, good care.