I wonder, what is the nursing history of the disease?

Medicine is full of various specific terms andconcepts that are clear only to the medical staff. Know them all the ordinary person simply can not. Therefore, in this article I want to talk about what the nursing history of the disease is.

About the concept

First of all, it is necessary to deal withterms that are the main ones in this article. So, what is the nursing history of the disease? First and foremost, this is an important medical document, which nobody should forget (both to the patient and to the health worker himself). As for the main purpose, this document should fully reflect all five stages of the nursing process in relation to one patient.

About stages

As it was said above, in order for the nursing history of the disease to be filled correctly, the health worker must go through with his patient five main stages.

1. Collecting information about the patient and his conditionhealth. Here the name of the patient, his age, sex will be indicated. As well as examination data, laboratory and instrumental studies (if such were done).
2. The next not less important stage is the formulation and definition of the main problems of the patient (of course, related to health).
3. The third stage is the competent drawing up of a plannursing interventions, which is based on the priority of the patient's problems. In this case, the nurse should also set short-term and long-term goals.
4. The fourth stage: the implementation of the plan of nursing intervention as prescribed by the doctor, and independently (preparation for research, thermometry, etc.).
5. The most important stage: Analysis of the patient's reactions to nursing interventions. The criteria for this are as objective (normalization of body temperature, improvement of laboratory test results), and subjective indicators (sleep normalization, pain reduction).

Decor

It should be said that the sister storyDisease therapy (as well as a different section of medicine, such as surgery or pediatrics) should be filled by all the rules. So, a nurse must always observe special requirements for the design of this document:

1. All lines must be filled with a neat, even, readable handwriting.
2. It is necessary to strictly follow the form, which fills the nursing history of the disease.
3. The wording should be concise and accurate, conclusions - logical.
4. The information displayed in the nursing history of the disease should be as saturated and complete as possible.
5. The document must be clean.

After the nursing history of the disease has been filled, this document is reinforced to a folder with other papers relating to a particular patient.

Example

In this article, you also want toConsider how the nursing history of the disease can look like in therapy. So, it is worth saying that it is filled in according to the established 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 for her own work, that is, special medical measures for an individual patient. So, it can be a table of the following format:

date

Problem of the patient

The goal (i.e., the expected result)

Nurse actions

Patient assessment frequency

End date of goal achievement

Final assessment of the work of a nurse

In each cell, the nurse must complete theinformation about what needs to be done and what was done about the patient. The ultimate goal of this document is a comparison of the previously set goals and the results of nursing care. It should be said that, based on this data, even the patient's treatment by his doctor can be adjusted.