Medicine is full of various specific terms and concepts that are clear only to medical staff. An ordinary person simply cannot know them all. Therefore, in this article I want to talk about what a sister's medical history is.
About the concept
First of all, you must understand the terms that are dominant in this article. So what is a nursing medical history? First of all, this is an important medical document that should not be forgotten by anyone (both the patient and the health worker himself). As for the main purpose, then in this document all five stages of the nursing process should be fully reflected in relation to one patient.
About the stages
As already mentioned above, in order for the nursing medical history to be correctly completed, the health care provider must go through five main stages with his patient.
- Collection of information about the patient and his state of health. It will indicate the name of the patient, his age, gender. As well as inspection data, laboratory and instrumental studies (if any).
- The next no less important stage is the formulation and definition of the main problems of the patient (of course, related to health).
- The third stage is the competent preparation of a plan for nursing interventions, which is based on the priority of the patient's problems. In this case, the nurse must also set short-term and long-term goals.
- The fourth stage: the implementation of the plan of nursing intervention both as prescribed by the doctor and independently (preparation for research, thermometry, etc.).
- The most important stage: analysis of the patient's reactions to nursing interventions. In this case, the criteria are both objective (normalization of body temperature, improvement of laboratory tests), and subjective indicators (normalization of sleep, pain reduction).
Decor
It is worth saying that the nursing history of the disease in therapy (as well as in another section of medicine, such as surgery or pediatrics) must be filled out in accordance with all the rules. So, the nurse must comply with the special requirements for the design of this document:
- All lines should be filled in a neat, even, readable handwriting.
- Be sure to strictly follow the form in which the nursing medical history is filled.
- The wording should be concise and accurate, the conclusions logical.
- The information displayed in the nursing medical history should be as saturated and complete as possible.
- The document must be clean.
After the completion of the nursing medical history, this document is attached to the folder with other papers relating to a particular patient.
Example
In this article, I would also like to roughly consider what a nursing medical history of a disease might look like. So, it is worth saying that it is filled in the prescribed form, often all questions are printed, and the nurse can only write down the answers to them. At the same time, the nurse must also draw up a plan of her own work, that is, special medical measures for an individual patient. So, it can be a table of approximately the following format:
the date | Patient problem | Goal (i.e. expected result) | Nurse Actions | Frequency of patient assessment | End date for goal achievement | Final assessment of the work of a nurse |
In each cell, the nurse must enter complete information about what should be done and what was done about the patient. The ultimate goal of this document is to compare the goals set previously and the results of nursing care. It is worth saying that on the basis of these data, the treatment of a patient by his doctor can even be adjusted.