home Adviсe Observation chart for a patient undergoing inpatient treatment. Nursing medical history - filling out and using Nursing card for an inpatient patient in a therapeutic department

Observation chart for a patient undergoing inpatient treatment. Nursing medical history - filling out and using Nursing card for an inpatient patient in a therapeutic department

Educational medical history

Therapy patient

Completed by student

Gelmutdinova L.M.

Group 41-C

Methodical supervisor

Gilmiyarova A.N.

Grade______________________

Name of medical institution

Kiginskaya Central District Hospital

Nursing history No. 123 (educational)

inpatient

Date and time of admission 05/02/2015

Date and time of discharge 05/14/2015

Therapeutic ward No. 4

Transferred to department……………………………………………………………………

Number of bed days spent 13

Types of transportation: on a gurney, on a chair, can go

(emphasize)

Blood type O(I) Rhesus +

Side effects of medications - denies

(name of the drug, nature of the side effect………………..

1. Last name, first name, patronymic Arslanova Razina Rishatovna

2. Gender of women 3. Age 65 years (full years, children under 1 year - months, up to 1 month - days).

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

Kiginsky district, Arslanovo village, Molodezhnaya st., no. 4

(enter address, region, district, locality, address

89625295789__________________________________________________

relatives and phone number).

5. Place of work, profession, position, pensioner

________________________________________________________

(for students the place of study, for children - the name of the nursery

institutions, schools);

for disabled people – gender and disability group, a.i.v., yes, no

(emphasize)

6.Who referred the patient to clinic No. 1

12 hours after the onset of the disease or injury;

hospitalized as planned(emphasize)

8. Medical diagnosis Chronic obstructive bronchitis. DN - I

· The reason for petition:

1. The patient’s opinion about his condition – he wants to get better

2. Expected result – wants to get better

· Source of information (underline):

patient, family, medical documents, medical staff and other sources

Patient's ability to communicate: Yes, No

Speech: normal, absent, broken (underline)

Vision: normal, reduced, absent

Hearing: normal, reduced, absent

· Patient complaints: cough, shortness of breath, fever, general weakness, headache.

At present:

· Disease history:

When did it start - considers himself sick for the last 15 years

How it started - related to work, work was associated with unfavorable temperature conditions.

How it proceeded - in the autumn - winter period it worsened

The studies performed include chest x-ray, ultrasound of the liver and kidneys, full blood test, blood biochemistry, macroscopic examination.

Treatment, its effectiveness - the effect of treatment is positive.

· Life story:

The conditions in which he grew up and developed (living conditions) are normal

Working conditions, occupational hazards, environment - cleaning lady, work was associated with unfavorable temperature conditions.

Previous illnesses, surgeries – appendectomy, surgery for removal of nodular uterine fibroids.

Sexual life (age, contraception, problems) -

Gynecological history: (onset of menstruation, frequency, pain, profuseness, duration, last menstruation, number of pregnancies,

childbirth, abortion, miscarriages, menopause - age) onset at 13 years old, last menstruation at 49 years old, one pregnancy, miscarriages - 0, abortions - 0, menopause at 49 years old.

Allergic history:

food intolerance - denies

drug intolerance - denies

intolerance to household chemicals - denies

Dietary features: (what he prefers) – no special preferences

Bad habits: no

Does the patient smoke (since how old, how much per day) no

attitude towards alcohol (underline)

(doesn't use, moderate, excessive)

Lifestyle, spiritual status (culture, beliefs, entertainment, recreation, moral values) believes in God

Social status (role in the family, at work/school, financial situation) widow, has a son.

Heredity (presence of the following diseases in blood relatives: (underline) diabetes, high blood pressure, heart disease, stroke, obesity, tuberculosis,

cancer, stomach diseases, bleeding, allergies,

diseases of the kidneys, thyroid gland).

· Physiological data. Objective research:

(Underline whatever applicable)

3.Consciousness: clear, tangled, absent

4. Position in bed: active, passive, forced

5. Height 153 cm

6. Weight 92 kg

7. Temperature 37.5

8. Condition of the skin and mucous membranes:

turgor, humidity – dry skin, reduced turgor

color (hyperemia, pallor, jaundice, cyanosis)

defects, bedsores (yes, No)

swelling (yes, No)

lymph nodes (enlarged, not enlarged)

9.Musculoskeletal system:

skeletal deformation (yes, no) without changes

deformation of the joints (yes, no) deformation of the wrist joints of both hands

muscle atrophy (yes, No) pain in the spine

10. Respiratory system:

number of respiratory movements: 26 per minute

deep breathing, superficial(emphasize)

rhythmic breathing (yes, no)

nature of shortness of breath: expiratory, inspiratory, mixed

chest excursion:

symmetry ( Yes, no) symmetrical

cough ( Yes, no) wet

sputum ( Yes, no) difficult to separate

character of sputum: purulent, hemorrhagic, serous, foamy, mucous membrane

smell (specific) yes, No

Auscultation of the lungs:

breath: vesicular, rigid - symmetrical

wheezing: presence, absence – fine bubbling wheezing in the midline

11.Cardiovascular system:

Pulse (frequency, filling, tension, rhythm, symmetry) of normal filling and tension

Heart rate 80 pulse deficit

A/D on both hands: left, 140/80 right 140/90

Swelling - no

12. Gastrointestinal tract:

appetite: not changed, reduced, elevated, absent

swallowing: normal, difficult

removable dentures (yes, No)

tongue: coated (yes, no) moist. Not covered with plaque

vomiting: (yes, No)

nature of vomit

chair: decorated, constipation, diarrhea, incontinence, impurities (blood,

pus, mucus)

belly: increased in volume (%) rounded, slightly increased in size

flatulence, ascites - no

asymmetrical (yes, no) – slightly increased in size

pain on palpation (yes, No)

tense (yes No)

13. Urinary system:

urination:

free, difficult, painful, rapid

urine color: ordinary, changed, (hematuria), “meat slop”,

beer color, transparency - transparent

14. Endocrine system:

hair pattern: male, female

distribution of subcutaneous tissue is normal

visible enlargement of the thyroid gland (yes, No)– no visible enlargements

signs of acromegaly: (yes, No)

gynecomastia: (yes, No)

15. Nervous system: the psyche is not impaired

sleep: normal, restless, insomnia - due to shortness of breath

tremor - normal

gait disturbance: - gait is not disturbed

paresis, paralysis: - not available

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STATE BUDGET EDUCATIONAL

INSTITUTION OF HIGHER PROFESSIONAL EDUCATION

"IVANOVSKAYA STATE MEDICAL ACADEMY"

MINISTRY OF HEALTH OF THE RUSSIAN FEDERATION

Department of Propaedeutics of Internal Diseases

Educational and researchUniversity student work

NURSING HISTORY OF THE PATIENTTHERAPEUTICBRANCHES

Completed by: Voevodina V.I.,

5th group 2nd year student of medical faculty

Checked by: assistant, Tkachenko N.M.

Ivanovo, 2015

1. Patient's nursing historytherapeuticdepartments

Full name of student, group: Voevodina Vlada Igorevna, 5th group

Name of medical institution: OBUZ First City Clinical Hospital

General information:

Department: therapeutic.

Referred to: SMP.

Type of transportation: independent (can walk)

Sent to the hospital for emergency reasons, 24 hours after the first complaints appeared.

Passport details:

Patient's full name, date of birth: Nadezhda Stepanovna Babaeva, 73 years old (born October 24, 1941)

Home address: (who to contact if necessary). G. Ivanovo, st. Leningradskaya, 5, apt. 168 (if necessary, contact your husband, Vladimir Anatolyevich Babaev, t. 89150425668)

nursing examination henderson self-care

2 . Patient examination

1. Complaints upon admission:

For pain in the lower lobe of the right lung, an increase in blood pressure up to 180 mm Hg, elevated temperature, productive cough.

2. History of the development of the present disease.

According to the patient, she felt unwell on 04/13/15 in the morning, with scant discharge; After some time, the condition worsened and the body temperature rose.

There was no outpatient treatment and she was not treated independently. In the evening she called an ambulance, after which she was hospitalized in the therapeutic department of the Regional Clinical Hospital No. 1

3. Medical diagnosis (brief):

Community-acquired focal pneumonia in the lower lobe of the right lung, chronic bronchopneumonia

4. Life story.

She was born in the Ivanovo region, did not walk until she was five years old (rickets), and since childhood she suffered from respiratory diseases 2-3 times a year (chronic bronchitis) and pneumonia.

As an adult, she underwent surgery to remove part of the fundus of the stomach, an appendictomy, removal of stones from the ureter, and removal of cataracts.

There are allergic reactions to antibiotics. She graduated from 10th grade of secondary school. She worked as a diaerator operator and retired at the age of 50. Considers production conditions unsatisfactory. She lives with her husband in a two-room apartment with good conditions. Two children died. There are grandchildren.

Material and living conditions are satisfactory. Has no bad habits.

Meals are satisfactory 4 times a day. Denies sexually transmitted diseases, tuberculosis, viral hepatitis, and diabetes mellitus. Gynecological history of pregnancy: childbirth - 2, abortions - 0. Heredity is not burdened.

5. Concomitant diseases:

Mitral valve insufficiency, rheumatism, incomplete blockade of the right bundle branch.

6. Nursing physical examination

General condition is satisfactory. Consciousness is clear. Position active.

The emotional state is positive. There is a need for communication.

Body type: mesomorphic. Height 161 cm. Weight 77 kg. BMI = 29.7. The type of constitution is normosthenic.

Condition of the skin: The skin is of normal color and moisture, clean, visible mucous membranes are pale pink, moist, clean. Birthmark in the neck area from the front side. Soft tissue turgor is normal. The subcutaneous fat layer is expressed moderately, according to the female type, the stomach and thighs are the places of greatest deposition. Body temperature in the morning 36.2 ° , evening 36.8 ° .

Musculoskeletal system: No visible pathological changes: correct posture, full range of joint movements, painless, muscle tone preserved, painless movements.

Respiratory system: Breathing through the nose is not difficult. The chest is of the correct shape. 16 per min. Chest breathing type.

The cardiovascular system: Pulse 70 per minute, arrhythmic, satisfactorily relaxed in both arms. Blood pressure on the left arm is 140/75 mmHg, blood pressure on the right arm is 140/70 mmHg. The heart area is visually unchanged.

Digestive system: Appetite preserved. Examination of the oral cavity and pharynx: the tongue is moist, slightly coated at the root, without rashes. The abdomen is soft, painless, and of normal shape. Chair daily, decorated.

Urinary system: Swelling in the lower extremities. Pasternatsky syndrome is negative. Urination 4-6 times a day, painless, 1 time at night.

Endocrine system: without visible pathologies.

Blood system: Peripheral lymph nodes in the main groups are not enlarged (submandibular, anterior cervical, axillary, inguinal). Painless, elastic consistency, not welded together and surrounding tissues.

Treatment provided:

1) Ceftriaxone 1.0 i.v.

2) Erythromycin 0.2 + Sol. Vit.C. 0.9% 200 ml IV drop

3) Sol. Glucosae 5% 200 ml + Sol. Vit.C IV drip

3 . Pstopping nursing diagnosis

(identifying the patient's problems,assessment of violated needs according to W. Henderson’s classification,assessment of self-care ability using the Barthel scale)

Patient problems: development of an inflammatory process in the lung, severe productive cough, increased blood pressure and temperature; (need for communication, need for hobbies).

Ability Assessmentself-care: the patient does not need outside help in self-care.

Priority physiological problems: complication of the inflammatory process

in a lobe of the lung (possibility of abscess).

Psychological problems: isolation from family.

Social problems: fear of losing relatives.

Possible emergency conditions: acute respiratory failure, pleurisy (purulent), suppurative processes in the lungs (abscesses), stroke, angina.

4 . Nursing intervention planand ways to implement it

Problems patient	Patient problem solving plan (dependent and independent nursing manipulations)
Development of an inflammatory process in the lung. The goal is to prevent the development of complications.	1. Provide physical and emotional peace. 2. Ensure that body temperature is measured 2 times a day and recorded on a temperature sheet. 4. Monitor the patient's fluid intake.
Increased blood pressure.	1. Provide emotional and physical peace. 2. Ensure adequate daytime and night sleep. 3.Monitor blood pressure and heart rate regularly. 4. Ensure regular ventilation of the room and control of transmissions from relatives. 5. Ensure diuresis control. 6. Ensure the patient is prepared for laboratory and instrumental studies (ECG, blood test, CBC, OAM) 7. Organize a dietary diet with limited amounts of salt, liquid and fatty foods consumed as prescribed by a doctor.
Identification of emergency conditions. Goal: prevent risk to the patient's life.	1. Regularly monitor the patient’s consciousness, pulse, blood pressure, and breathing. 2. Carry out daily thermometry.
Severe productive cough.	1. Ensure regular intake of thinners and expectorants. 2. Ensure regular medication intake.

5. Follow the care plan

A. Preparationto radiography.

1) Explained the need and essence of the procedure being performed.

2) Obtained the patient’s consent for this procedure.

3) She ensured that the patient was prepared for the procedure, warning that it was necessary to remove metal jewelry.

4) Accompanied the patient to the office, taking her medical history with her.

5) Waited for the procedure to complete. 6) Accompanied the patient to the room.

B. Preparation and collection of general sputum analysis.

Target: ensuring high-quality preparation for research, information and training, ensuring storage and delivery of material for research.

Indications: disease of the respiratory system and cardiovascular system.

Equipment: clean wide-headed glass jar made of transparent glass, disinfectant solution 5% chloramine solution, 2% sodium bicarbonate solution.

Preparation for the procedure:

1. Establish a trusting relationship with the patient.

2. Warn and explain the meaning and necessity of the upcoming study and obtain consent to carry out the procedure.

3. Conduct instructions: brush your teeth 2 hours before collecting sputum (it is better not to brush at all), rinse your mouth and throat with boiled water immediately before collection.

Performing the procedure:

1. Cough and collect sputum in a clean jar of at least 3-5 ml.

End of the procedure:

1. Attach the referral and deliver to the clinical laboratory within 2 hours.

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Anamnesis morbi

He considers himself sick since the morning of March 25, when pain appeared in the epigastric region, followed by nausea and weakness. The pain, according to the patient, was of moderate intensity, aching in nature, spread throughout the epigastric region without clear localization, and constant. In addition to pain and nausea, the patient developed anorexia, and therefore he did not want to take his morning meal. The pain did not go away and over time (by 13-15 hours) moved to the right iliac region. By 4 p.m., the patient noted constant, periodically cramp-like pain in the abdominal area with predominant localization in the right iliac region, nausea and weakness persisted, and by the same time the patient developed chills.

Due to the deterioration of his condition, at 20:30 the patient called an ambulance, which was taken to City Clinical Hospital No. 1 to clarify the diagnosis and carry out treatment.

Anamnesis vitae

Born in 1981 in the village of Rogozikha, Pavlovsk district, as a child he moved to permanent residence in Barnaul, where he lives to this day. I rarely suffered from inflammatory diseases in childhood. Finished 11 classes of high school. At the age of 18 he entered the BYU, where he is currently studying.

According to the patient, he does not suffer from chronic diseases of the gastrointestinal tract and other organs.

Denies blood transfusions and major operations. Denies tuberculosis, viral hepatitis, sexually transmitted diseases. There is no allergic history.

There are no bad habits. Denies any criminal record.

Currently, social living conditions are satisfactory; he lives in a comfortable apartment with his parents.

Status praesens communis

The general condition of the patient is satisfactory, consciousness is clear. The patient's position in bed is free. The facial expression is calm, the behavior is normal, emotions are restrained. The posture is correct, the physique is correct. The patient has a moderate diet. The constitution is normosthenic. The patient's height is 177 cm, weight 78 kg.

Skin, peripheral lymph nodes and mucous membranes:

The skin is of normal color, temperature and humidity. Skin turgor is not reduced. Subcutaneous fatty tissue is moderately expressed. The oral mucosa is pale pink, no pathological changes were detected. Peripheral lymph nodes are not enlarged.

Musculoskeletal system:

The general development of the muscular system is normal, muscle tone is not reduced. There is no pain when palpating the muscles, no atrophy or thickening was detected. There are no bone deformities or pain during tapping. The configuration of the joints has not been changed.

Respiratory system:

The respiratory rate is 16 breaths per minute, rhythmic breathing. Nasal breathing is not difficult. The voice is not muffled. The shape of the chest is normal, both halves are symmetrical, and participate equally in the act of breathing.

When palpating the chest, the skin temperature in symmetrical areas is the same, no pain was detected. Resistance is not increased, vocal tremors are uniform.

With comparative percussion, there is no dullness of percussion sound.

With topographic percussion:

height of the apex of the lungs on the right 3 cm, on the left 4 cm

Krenig margin width on the right 6 cm, on the left 6 cm

the boundaries of the pulmonary edge and its mobility are within normal limits.

Auscultation: vesicular breathing is heard at all points.

The cardiovascular system:

Pulse 74 beats per minute, rhythmic. The apical impulse is palpated in the 5th intercostal space 1.5 cm medially from the midclavicular line.

Limits of relative dullness of the heart

Right In the IV intercostal space 1.5 cm lateral to the right edge of the sternum Left In the V intercostal space on the left 1.5 cm medially from the midclavicular line Upper In the III intercostal space on the left along the parasternal line

Limits of absolute dullness of the heart

Right Left edge of the sternum in the IV intercostal space Left 3 cm medially from the midclavicular line in the V intercostal space Upper At the left edge of the sternum in the IV intercostal space

The width of the vascular bundle along the spine does not extend beyond the edges of the sternum.

Auscultation: the rhythm is correct, heart sounds are clear, of normal volume at all points.

Heart rate 74 beats/min, blood pressure 120/80 mmHg. Art.

Urinary system:

Examination of the lumbar region revealed no edema or swelling. With deep palpation, the kidneys are not palpable. The symptom of effleurage is negative. The bladder is painless on palpation. Urination is painless, regular, 3-5 times a day.

Neuroendocrine system:

The patient's consciousness is clear. Sensitivity is not changed. Secondary sexual characteristics of the male type. The thyroid gland is not enlarged and painless on palpation.

Status localis

At the time of admission: the tongue is moist, the abdomen is not swollen, there are no symptoms of peritoneal irritation, pain in the right iliac region.

At the time of inspection: When examining the oral cavity: the tongue is moist, pink, without plaque, the tonsils are not enlarged, the palatine arches are unchanged. The oral mucosa is moist, pink, and clean. The gums are free of inflammation and do not bleed. The act of swallowing is not impaired.

Examination of the abdominal area: the skin of the abdomen is of normal color, the abdomen is symmetrical, participates in the act of breathing, no visible bulges were found. A dry bandage is visible in the right iliac region.

On palpation: the skin is of moderate humidity, turgor and elasticity are not changed, the temperature in symmetrical areas is the same, not increased. Subcutaneous fat is moderately expressed, no pathological formations were identified. There is no discrepancy between the muscles of the anterior abdominal wall. Muscle tone is normal, the same in all muscle groups. Symptoms of peritoneal irritation are negative.

With deep palpation of the liver, the lower edge of the liver does not protrude from under the edge of the costal arch; it has a dense elastic consistency and is painless. The gallbladder is painless on palpation. Orter's sign is negative.

Percussion liver dimensions according to Kurlov: 8/9/10 cm.

The spleen is painless, normal size and location.

Pecutorno: no free fluid is detected in the abdominal cavity. The fluctuation symptom is negative. No gas was detected in the abdominal cavity.

Auscultation: sound of intestinal peristalsis.

Preliminary diagnosis

Based on the patient’s complaints of constant aching pain in the right iliac region, of moderate intensity, nausea, and weakness, it can be assumed that the digestive system is involved in the pathological process. Considering the localization of pain, it can be assumed that the process is located in the abdominal cavity, in the right iliac fossa.

From the medical history it is known that the first symptoms of the disease appeared on the morning of March 25, on the same day the deterioration of the patient’s condition forced him to seek help from a doctor. This allows us to conclude that the process is acute. According to the patient, pain in the epigastric region, nausea, and weakness initially appeared. The pain did not go away and eventually moved to the right iliac region. By 5 p.m., the patient noted constant, periodically cramping-like pain of moderate intensity in the abdominal area with predominant localization in the right iliac region. These signs indicate the presence of Kocher's pain displacement symptom.

From the general status it is known that the severity of the patient’s condition is not threatening. No pathologies from other organ systems other than the digestive organs were identified, this confirms the absence of complications of the underlying disease.

The following is known from the local status: the abdomen is not distended, there are no symptoms of peritoneal irritation, local pain on palpation in the right iliac region. These data also confirm the assumption that the pathological process is localized in the right iliac fossa, without involving the parietal peritoneum in the pathological process.

Thus, based on the above, a preliminary diagnosis can be made: acute catarrhal appendicitis.

Additional examination methods

Plan:

v General blood test

v General urine analysis

v Diagnostic laparoscopy

Results:

Hemoglobin 155 g/l

Leukocytes 7.8x10 9 /l

Hematocrit 0.46

General blood test dated 03/25/03:

Hemoglobin 150 g/l

Red blood cells 4.5×10¹²/l

ESR 26 mm/h

Platelets 300x10 /l

Leukocytes 16.1x10 /l

General blood test dated 04/31/03:

Hemoglobin 150 g/l

Red blood cells 4.5×10¹²/l

ESR 25 mm/h

Platelets 300x10 /l

Leukocytes 6.6x10 /l

General clinical urine analysis dated March 25, 2003:

Quantity: 240 ml

Density: 1017 mg/l

Yellow color

Transparency: full

Protein: negative

Epithelial cells: single.

Salts: oxalates

General clinical urine analysis dated 04/31/03:

Quantity: 240 ml

Density: 1017 mg/l

Yellow color

Transparency: full

Protein: negative

Leukocytes: 2 cells. in sight

Red blood cells: 0 cells. in sight

Epithelial cells: single.

Slime: negative

Salts: negative

Diagnostic laparoscopy from 03.25.03 (22:40):

Examination under local anesthesia Sol Novocaini 0.5% - 100 ml. The abdominal cavity is dry. The vermiform appendix is located medially, moderately hyperemic, dense, and tense. Other organs are unremarkable.

Conclusion: acute appendicitis

Biopsy sheet dated 03/25/03:

Description of the material being sent: appendix, length 11 cm, diameter 0.6 cm

Clinical data: appendicitis clinic

Date of operation: 03/25/03

Clinical diagnosis: catarrhal appendicitis

Pathological diagnosis: catarrhal appendicitis

Patient management plan

Emergency surgical treatment

v Premedication: 30 minutes before surgery Sol Promedoli 2%-10 ml IM

v Surgery for appendectomy

Postoperative period

v On the first day, two days: pastel regime, diet No. 4, medicinal pain relief (Analgin, Diphenhydramine)

v In the following days: free regimen, with limitation of muscle tension of the abdominal wall, general diet, regular dressing changes, and wound control

v Removal of sutures on day 7

Operation protocol:

23:00 Under aseptic conditions under local anesthesia with Novocaine (Sol Novocaini 0.5%-300.0), the abdominal cavity was opened layer by layer using the Volkovich-Dyakonov approach. The dome of the cecum with the base of the appendix is brought out into the wound. The mesentery of the appendix is gradually clamped, crossed, stitched and bandaged. A typical appendectomy was performed with the stump immersed in a pouch and a Z-shaped suture. Hemostasis control - dry. The pelvis is dry. A suture and an aseptic bandage are applied to the wound in layers.

Macro specimen: appendix about 11 cm long, up to 0.6 cm in diameter with injected vessels.

Clinical diagnosis

The preliminary diagnosis is confirmed by the results of additional research methods.

In the CBC, there is an increased content of leukocytes, a shift in the leukocyte formula to the left, which indicates an acute inflammatory process. Diagnostic laparoscopy revealed acute appendicitis.

That. the final diagnosis will be as follows: acute catarrhal appendicitis.

Etiology and pathogenesis of the underlying disease

Causes.

1. Obstruction of different etiologies:

a) fecal stones;

c) tumors

d) measles – the measles virus is tropic to the lymph nodes of the appendix, which leads to their enlargement and closure of the lumen of the appendix;

2. Follow-up infection(by sowing frequency):

a) Bacteroides fragilis (and other anaerobes)

b) Escherichia coli (in isolation, in the worst case, causes catarrhal appendicitis)

Pathogenesis.

After obstruction of the lumen of the appendix, its secretory function continues to be performed. Against the background of a lack of secretion outflow, intra-appendicular pressure increases over time. The peripheral blood supply to the appendix is disrupted, ischemia occurs and zones of necrosis are formed. Ischemic and necrotic areas of the appendix wall are not able to perform specific and nonspecific protective functions and are susceptible to infection anaerobic flora.

Diary

Subjectively, the patient feels satisfactory. Complains of mild pain under the bandage. Consciousness is clear, position is active. Body temperature 36.7. The pulse is normal, heart rate 76 beats. per minute On auscultation, heart sounds are rhythmic and not muffled. Blood pressure 120/80. In the lungs there is vesicular breathing, with percussion there is a clear pulmonary sound. Respiration rate 16/min.

Status localis: When examining the oral cavity: the tongue is moist, pink, without plaque. Examination of the abdominal area: the skin of the abdomen is of normal color, the abdomen is symmetrical, participates in the act of breathing, no visible bulges were found. A dry bandage is visible in the right iliac region. On palpation: the skin is of moderate humidity, turgor and elasticity are not changed, the temperature in symmetrical areas is the same, not increased. Subcutaneous fat is moderately expressed, no pathological formations were identified. There is no discrepancy between the muscles of the anterior abdominal wall. Muscle tone is normal, the same in all muscle groups. Symptoms of peritoneal irritation are negative. With deep palpation of the liver, the lower edge of the liver does not protrude from under the edge of the costal arch; it has a dense elastic consistency and is painless. The gallbladder is painless on palpation. Orter's sign is negative. Auscultation: sound of intestinal peristalsis.

Subjectively, the patient feels satisfactory. He makes no complaints. Consciousness is clear, position is active. Body temperature 36.5. Pulse is normal, heart rate 70 beats. per minute On auscultation, heart sounds are rhythmic and not muffled. Blood pressure 120/80. In the lungs there is vesicular breathing, with percussion there is a clear pulmonary sound. Respiratory rate 17/min.

Urination is painless. The amount of liquid drunk corresponds to the amount of urine excreted.

Subjectively, the patient feels satisfactory. He makes no complaints. Consciousness is clear and active. Body temperature 36.8. The pulse is normal, heart rate 74 beats. per minute On auscultation, heart sounds are rhythmic and not muffled. Blood pressure 115/80. In the lungs there is vesicular breathing, with percussion there is a clear pulmonary sound. Respiration rate 16/min.

Status localis: When examining the oral cavity: the tongue is moist, pink, without plaque. Examination of the abdominal area: the skin of the abdomen is of normal color, the abdomen is symmetrical, participates in the act of breathing, no visible bulges were found. There is a dry bandage in the right iliac region. On palpation: the skin is of moderate humidity, turgor and elasticity are not changed, the temperature in symmetrical areas is the same, not increased. Subcutaneous fat is moderately expressed, no pathological formations were identified. There is no discrepancy between the muscles of the anterior abdominal wall. With deep palpation of the liver, the lower edge of the liver does not protrude from under the edge of the costal arch; it has a dense elastic consistency and is painless. The gallbladder is painless on palpation. Auscultation: sound of intestinal peristalsis.

Subjectively, the patient feels satisfactory. He makes no complaints. Consciousness is clear and active. Body temperature 36.6. The pulse is normal, heart rate 74 beats. per minute On auscultation, heart sounds are rhythmic and not muffled. Blood pressure 115/80. In the lungs there is vesicular breathing, with percussion there is a clear pulmonary sound. Respiration rate 16/min.

Status localis: When examining the oral cavity: the tongue is moist, pink, without plaque. Examination of the abdominal area: the skin of the abdomen is of normal color, the abdomen is symmetrical, participates in the act of breathing, no visible bulges were found. There is a dry bandage in the right iliac region. On palpation: the skin is of moderate humidity, turgor and elasticity are not changed, the temperature in symmetrical areas is the same, not increased. Subcutaneous fat is moderately expressed, no pathological formations were identified. There is no discrepancy between the muscles of the anterior abdominal wall. With deep palpation of the liver, the lower edge of the liver does not protrude from under the edge of the costal arch; it has a dense elastic consistency and is painless. The gallbladder is painless on palpation. Auscultation: sound of intestinal peristalsis.

There are no pathological deviations from the urinary organs.

The prognosis for the life of this patient is favorable, because The development of postoperative complications after appendectomy for simple appendicitis is extremely rare. During observation and treatment in the hospital, there was a clear positive trend in the patient’s condition, which once again indicates a favorable prognosis.

The prognosis for the patient's ability to work is also favorable. This confirms the safety of all vital organ systems and the patient’s ability to perform full work activities 1 month after the operation.

Epicrisis

Patient D.V. Kolosov, 21 years old, was hospitalized in the surgical department No. 1 of City Clinical Hospital No. 1 from 03.25.03 to 04.1.03; was admitted to the hospital on March 25, 2003 by ambulance.

Main diagnosis: acute catarrhal appendicitis

He was admitted with suspected acute appendicitis.

Upon admission, she complained of pain in the right iliac region, nausea, and general weakness. An objective examination revealed: the tongue is moist, the abdomen is not swollen, there are no symptoms of peritoneal irritation, pain in the right iliac region. No pathological abnormalities were identified in other organ systems. Pulse 76 beats min, blood pressure 125/80 mm Hg. Additional examination revealed:

General blood test dated 03/25/03:

Hemoglobin 155 g/l

Leukocytes 7.8x10 9 /l

Hematocrit 0.46

Quantity: 240 ml

Density: 1017 mg/l

Yellow color

Transparency: full

Protein: negative

Leukocytes: 2 cells. in sight

Red blood cells: 0 cells. in sight

Epithelial cells: single.

During his hospital stay he received the following treatment:

Operation No. 1 from 03.25.03 at 22:40: diagnostic video laparoscopy

Operation No. 2 from 03.25.03 at 23:20: appendectomy

He received treatment in full, the postoperative period was without complications. The stitches have been removed. The surgical wound healed by primary intention. After treatment, the patient's condition improved. He makes no complaints, objectively: no deviations from the organ systems were identified. Clinical recovery has occurred.

Upon discharge:

General blood test dated 03/31/03:

Hemoglobin 150 g/l

Red blood cells 4.5×10¹²/l

ESR 25 mm/h

Platelets 300x10 /l

Leukocytes 16.1x10 /l

General clinical urine test dated 02/26/03:

Quantity: 240 ml

Density: 1017 mg/l

Yellow color

Transparency: full

Protein: negative

Leukocytes: 2 cells. in sight

Red blood cells: 0 cells. in sight

Epithelial cells: single.

Slime: negative

Ø Limiting physical activity accompanied by muscle tension in the anterior abdominal wall for 1 month.
Dispensary registration with a surgeon at your place of residence

References

Nikitin Yu.P. “Everything about patient care”, Moscow, 1999
Kuzin M I “Surgical diseases”, Moscow, M, 1986
Material from the Internet: www.corncoolio.narod.ru

You can use this surgical medical history

Name of medical institution BMU KOKB

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

Branch Toardiological 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, Anakhino village, st. Lesnaya, 1

Place of work, profession, position pensioner

Emergency phone number tel. 26-45-01

Directed by Kursk district clinic

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, flashing spots before the eyes.

Subjective data

Objective data

Patient problem

BREATH

Shortness of breath: yes No

Cough: yes No

Sputum: yes No

Is a special position required in bed:

Yes No

____________________________________________________________

Coloring of skin and mucous membranes pale

Breathing rate 16 per minute

Breathing depth medium depth

Breathing rhythm rhythmic

Dyspnea (expiratory, inspiratory, mixed)

Sputum (purulent, bloody, serous, foamy)

Smell: yes No

Pulse 92 in min.; rhythmic arrhythmic

HELL 180 / 100 mmHg .

Pulse is hard and tense

PROBLEM IDENTIFIED:

Tachycardia

Increased blood pressure (hypertension)

FOOD AND DRINK

Thirst: yes No

Appetite (maintained increased demoted absent)

What does he prefer? fried, fatty foods

Errors in diet: Yes No

Dyspepsia (heartburn, belching, nausea, vomit)

Dry mouth: yes No

Ability to feed independently: Yes No

does not know about diet for high blood pressure

Diet No. 10

Height 179 see weight 85 kg

Proper weight 79 kg

Daily fluid intake 1000 ml

Character of 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 and diet

HIGHLIGHT

Stool frequency 1 time per day

Character of stool (liquid, decorated)

Pathological impurities No

Fecal incontinence: yes No

Urination (normal, painful, difficult, incontinent, incontinent)

Daily amount 700 ml

Gets up at night: yes No

Ability to use the toilet independently: Yes No

Sister's additions/comments: _____________

Colostomy (ileostomy) No

Bloating: Yes No

Character of urine ( regular cloudy, the color of beer, meat slop)

Catheter No

_________________________

Cystostomy: yes No

_________________________

Edema: yes No

PROBLEM IDENTIFIED:

Not identified

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

Bed comfort: Yes No ______________

Sister's additions/comments: _____________

Sleeps at night: Yes No

During the day: 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 one’s hair, take care of the oral cavity, wash the entire body, and change clothes Yes

Sister's additions/comments: _____________

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

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

Turgor saved

Bedsores No

Other defects (scratching, diaper rash) No

Mucous membranes clean

Smell from the mouth: Yes No

Lingerie ( pure, dirty)

Sanitation ( full, partial)

PROBLEM IDENTIFIED:

Not identified

MAINTENANCE

temperatureBODIES

Chills: yes No

Feeling hot: yes No

Sister's additions/comments: _____________

Body temperature 36,6 °C

____________________________________________________________________________________________________

PROBLEM IDENTIFIED:

Not identified

SAFETY

Risk factors:

Allergy No

Smoking I do not smoke

Alcohol (too much) No

Falls: yes No

Frequent stressful situations: yes No

Other No

Attitude to illness calm

Ability to self-administer medications There is

Need for information available

Pain yes, headache in the occipital region

What gives relief taking antihypertensive drugs, reclining position

Sister's additions/comments: 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 aids, removable dentures, cane, etc. No

Ability to independently maintain own safety: yes No

PROBLEM

RECOGNIZED:

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

MOVEMENT

Moves independently: Yes, No

Moves with help without outside help

Walks to the toilet: Yes No

Turns over in bed: Yes No

Sister's additions/comments: 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

Difficulty communicating No

Sister's additions/comments: _____________

Consciousness clear

Speech ( normal, broken, missing)

Memory age appropriate

Vision ( normal, violated)

Rumor ( normal, reduced)

PROBLEM IDENTIFIED:

Not identified

REST AND WORK

Leisure agricultural work in the garden

Work ability: yes No

Sister's additions/comments : cannot work or rest due to headaches and dizziness

PROBLEM IDENTIFIED:

Impaired performance and ability to rest

Violated needs:

Highlight.

Avoid danger.

To be healthy.

Move.

Work.

Relax and communicate.

Patient problems:

Real:

Hypertension.

Dizziness, spots flashing before the eyes.

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

Priority:

Headache in the occipital region associated with increased blood pressure.

Hypertension.

Potential:

Risk of deterioration.

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

	Supervision days
	1 day/	2 day/	3 day/
Priority medical problem for the day of supervision		Pain relief, antipyretics
Mode	Bed	Bed	Bed
Diet	Table No. 5	Table No. 5	Table No. 5
Hygiene (on your own, need help)	Help needed	Help needed	Help needed
Skin (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
NPV
Body temperature	38,5	37,8	37,2
Appetite	Reduced	Reduced	Reduced
Chair	Diarrhea, without impurities	Diarrhea	Normal
Urination	Normal	Normal	Normal
Dream	Sleeps in bed, needs daytime rest Night sleep: has difficulty falling asleep, often wakes up (needs sleeping pills)	Intermittent	Normal
Complications during drug administration (if any)	None	None	None

Observation chart for a patient undergoing inpatient treatment. Nursing medical history - filling out and using Nursing card for an inpatient patient in a therapeutic department

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II. Primary nursing examination sheet