nurse patient survey
patient survey is to collect information about the patient, which includes complaints of the patient, medical history, personal history, a physical examination.An important element in any examination of the patient is the opportunity to question him, to gather information through oral dialogue.
Asking the patient includes three main points.
1. Complaints about the patient's disease, with which he came to seek medical help.
2. The history of the disease, to which the patient is admitted for treatment.
3. The history of life.
patient complaints.A nurse should collect exactly the complaint that bother the patient at admission.From this the correct diagnosis, and hence the treatment of the patient directly depends.Most patient asks the doctor, but many clinics are moving in recent years on the European model, where it is engaged in a nurse, which transmits your doctor all the data.Asking held in the House or in the office, separate from other patients.The voice of the nurse is to be calm, steady, modera
most common complaint in many surgical diseases is pain.The pain is characterized by the following features: localization (location) and irradiation (which gives), time of occurrence, duration and intensity.It is important to find out the relationship of pain with certain factors (eg, physical work, trauma, eating, mental stress).The pain can be combined with a number of symptoms, such as dizziness, loss of consciousness, vomiting, and others. We need to find out whether the pain is reduced if the patient has taken any forced position (lying, half-sitting, standing).If vomiting occurs, you should find out how often it occurred, the nature of vomit, if it brings relief, what was accompanied by complaints.
history of the disease (a№ am№ esis morbi).The purpose of a history of the disease - is to obtain information about the beginning and the further development of the disease in chronological order.The clinical history should detail the development of the disease from the initial manifestations to the present.It is important to determine how much time elapsed from the onset of treatment to the patient's medical care.It is necessary to find out the cause of the disease (trauma, physical activity, exposure to chemical factors, heredity, etc..), The symptoms are manifestations of the disease during the period of this disease, their change, addressed whether the patient about their disease for medical help, if yes, whenfirst.It is necessary to know which diagnostic examination he passed (laboratory, instrumental), the results of these surveys, what treatment was applied to the proceeds of its effectiveness (for better or worse the patient feels after the prescribed treatment or his condition has not changed).If the patient can not remember the name of the drugs that received, let him take drugs with them or they will bring it close.Consideration should be available to the patient's medical records: discharge from the medical history, medical records of assays (lab tests, x-rays).
life story (a№ am№ esis vitae).The history of life - it is a brief biography of the patient's health.Its purpose is to clarify the relationship of conditions of life of the patient with the emergence and development of disease.
Life history is going on a definite plan.
1. Birth and childhood development.If possible, find out the gynecological history mother, she endured a pregnancy, in what time frame bore.We need to know what disease the child suffered childhood physical and motor and mental development in children.
2. Postponed disease in their lifetime (infectious, venereal, tuberculosis, chronic diseases), presence of chronic diseases, their course and duration of periods of exacerbation.An important moment in the history of life is to inquire about previous surgeries and injuries.
3. Gynecological history in women: physiology and pathology of the female reproductive organs, history of pregnancy and during labor.
4. An employment history.The main finding is occupational hazards at work.To professional harmful factors include physical and mechanical (vibration, noise, prolonged standing or sitting), chemical (work with chemicals, substances), biological (light, animal dander).
5. Family history.The main objective of the collection is a family history information about diseases of the patient closest relatives (parents).If the parents have died, it is necessary to know the cause of death.It is necessary to determine the presence of known genetic diseases (such as Down's syndrome, hemophilia).
6. Domestic history.Find out in which the patient lives living conditions: the presence of water in the apartment, heat, sewage, the amount of free space on one person, as a respected personal and household hygiene.
7. The presence of harmful habits of the patient: smoking, intake of alcohol, narcotic drugs.It is important to clarify how many cigarettes per day the patient smokes, what cigarettes fortress which alcoholic beverages uses the patient, how many times a week, day and in what quantities.If the patient is using drugs, it is important to find out the type of drug, duration of use of these drugs.
8. Allergic history.Nurse have to find out whether the patient has an allergy.If patients experience an allergic reaction, it is necessary to find out what it is.The important point is allergic to the medication.The patient should list all the names of drugs or medicines group, which cause allergic reactions.This will help avoid complications during treatment, and at the time of induction of anesthesia.
9. Infectious analysis: what infectious diseases sick man throughout his life, whether the patient has ever performed a blood transfusion.
Objective examination of the patient.An objective method of examination is based on a study of patient physical data, and includes an assessment and description of the different physical parameters.For each patient's physical examination is an important step in the overall scheme and serves to correct diagnosis and choice of method, type of treatment.An objective examination conducted a general examination of the patient and directly organ or organ system, complaints on the work which the patient sought medical help.Sightseeing is best done in the presence of natural light, in a warm, ventilated room.Hands nurse should be warm, with short nails.
overall patient examination. During the general examination of human consciousness is determined, the position of the patient, his general view, the state of the external skin and mucous membranes.
Consciousness patient .The consciousness of the patient is clear, confused, may be missing.Confusion occurs gradually, in several stages: stupor, stupor, coma.With the development of stupor in a patient impaired orientation in space.The person becomes sluggish, slow and did not immediately respond to questions, lowered overall reaction and local reflexes.When questioning the patient in a stupor has to ask again a few times, to raise your voice when speaking.Sopor - a pathological condition, when the patient is severely inhibited, responds to questions only when crying or when the doctor shakes him physically, it is as if in hibernation.Reflexes are depressed.Coma - a complete loss of consciousness of the patient.The man did not react to strong external stimuli.Reflexes are depressed or absent.
position of the patient. Determination of position of the patient is important in many therapeutic, surgical diseases (for example, spinal diseases, pathologies of internal organs).The position of the patient can be active, passive, involuntary.Active - when a person can own, it is easy to change your physical position easily (get up, sit down, bend over, lift the arm or leg, and others.).The active position is observed in normal healthy humans or in the presence of non-severe disease in a patient, in the beginning of its development.Passive - when a patient specific physical actions can not perform through the power, or it can not independently change the position.This happens in diseases of the spine, in the presence of contractures, paralysis or paresis, fractures or dislocations, diseases of internal organs.Forced - the patient takes this provision to relieve pain or other abnormal discomfort.For example, the patient takes a forced situation with asthma - orthopnea position: the patient to facilitate the state sits, leans forward with a focus on the hand.Often, the patient takes a forced situation for heart failure, pleurisy, asthma.At the turn of the limb patient also receives a forced position, which reduces pain.
Defining patient constitution. human constitution - this body type.The constitution of the patient depending on the body mud is asthenic, normosthenic, hypersthenic.Asthenic body type is characterized by the dominance of the longitudinal dimensions of the cross: a narrow thorax, ribs are arranged obliquely downward, supraclavicular and subclavian fossa and the intercostal spaces are well defined, the blades are spaced from the chest, epigastric angle is acute.Hypersthenic figure characterized by a broad chest with pronounced lateral parameters, epigastric angle is obtuse.A person with a well-developed physique hypersthenic muscle mass, it is small in stature, with a short neck and limbs.The man with the physique normostenicheskaya all parameters in the body are proportional.The chest is a cone, the blade firmly against your chest, epigastric angle straight.
condition of the skin and mucous membranes. important information about the patient's condition can give the nurse and physician examination of the skin and mucous membranes.On examination, the skin nurse should pay attention to color, purity, temperature, turgor (elasticity), skin dryness or humidity.
skin, depending on the color is pale, flushed, cyanotic, icteric.Pale skin is with anemia (eg, when a person has an internal or external bleeding).The skin with a bluish tint is observed in patients with cardiac or respiratory failure.With the jaundice - liver diseases.Sometimes the skin of patients with a bronze tint is observed in diseases of the adrenal glands.When cancer patients or sepsis (blood infection), skin becomes gray, with an earthy tone.
Clean skin. on human skin may have a variety of lesions, such as spider veins, petechiae, allergic reactions in form of urticaria, bruising, or hematoma.Also important is the presence of the changes after injuries, burns, frostbite.A nurse must examine the entire skin of the patient, rather than its separate parts.Tension of the skin provide information about their elasticity.Dehydration of the skin turgor is reduced, the elasticity decreases.Wet skin are at a fever, cardiovascular disease, and dry - with dehydration (when severe vomiting, diarrhea).Examination of the patient completes the definition of edema.Swelling there are external and internal, local, or may extend to the entire body (anasarca).Swelling often occur in diseases of the cardiovascular system, or the renal system.Dangerous are the internal swelling, they are more difficult to define.intradermal test is used to determine the internal swelling.
inspection organs and organ systems in patients
inspection organs and organ systems in patients nurse holds a special examination techniques.Data techniques include palpation, percussion, auscultation.
palpation (probing). Palpation produced using the fingers of the right and left hands.Hands nurse should be warm and dry, the skin - smooth, nails cut short.Palpation start away from the injury site or location of pain, gradually approaching it.Palpation is superficial (skin feeling and subcutaneous integument) and deep (feeling more deeply lying hypodermic formations: the internal organs, lymph nodes).With the help of a nurse palpation may reveal the location, shape, size, tumor or swelling due to inflammation.An important element is the palpation examination of peripheral lymph nodes.Palpation of the lymph nodes is performed in a specific order: first occipital and explore the parotid, then neck, submandibular and supraclavicular, axillary, elbow, inguinal and popliteal.Normally, a healthy person painless lymph nodes, up to 1 cm, are not connected with each other and with neighboring covers, mobile.
With palpation nurse can determine the pulse of the patient.Pulse is determined on the radial artery, brachial artery, femoral artery, popliteal artery, carotid artery.Pulse is characterized by filling, voltage, frequency and duration.Palpation of the abdomen is important in the diagnosis of acute diseases (appendicitis, enteritis, intestinal obstruction, acute peritonitis).For abdominal palpation method is used a model Strazhesko.With palpation nurse can determine the presence or absence of external swelling.When pressed on the skin with your finger in the presence of external swelling formed recess.
Percussion is an objective method for studying the surgical patient.Percussion percussion based on specific areas of the body and defining But there is no sound or the presence of pathological changes in the body.Percussion is used to determine the exact parameters of the internal organs and / or pathological focus (heart, lungs, liver).Percussion stomach used to detect fluid in the abdominal cavity with ascites.
Auscultation - an objective method for studying the patient, listening to the working organ sounds.Auscultation is of two types - direct and indirect.Indirect auscultation is carried out through a special device - a stethoscope, a straight line is directly through the ear health worker, which he applies to the patient's body.Auscultation is used for listening to heart, lung, hollow organs of the abdominal cavity.Auscultation of the heart determine the frequency, heart rate, noise.Auscultation of the lungs revealed abnormal wheezing noises.Auscultation intestinal peristaltic noises are determined, their presence or absence.