Data from laboratory and instrumental studies

NURSING HISTORY

DISEASES

CONTENT:

1. Title page of the nursing history.

2. Subjective examination.

3. Objective examination.

4. Data from laboratory and instrumental studies.

5. Diary of nursing supervision.

6. Evaluation of the medication taken.

7. Map of the nursing process.

Name of medical institution Mytishchi City Clinical Hospital

Nursing card of an inpatient, No. 1288133

Date and time of admission 01/12/2012

Date and time of discharge 23.01.2012

Therapeutic ward №1

Transferred to department

Stayed in bed – 12 days

Types of transportation: on a wheelchair, on a chair, can walk (underline)

Blood group O (I) Rhesus – belonging to Rh + (positive)

Individual intolerance to drugs (does not note, notes how

appears) does not mark

1. Surname, name, patronymic Potapenko Natalia Valerievna

2. Gender: male, female (underline)

3. Age 37 (full years, for children: up to 1 year – months, up to 1 month – days)

4. Permanent place of residence: city , village (underline) Mytishchi, Moscow region,

Olympiyskiy Ave, 19, bldg. 1, apt. 38, tel. (495) 583-44-65

(write down the address, indicating for non-residents – region, district)

(location, address of relatives and phone number)

5. Place of work, profession or position of Maritime Transport RU LLC, manager

(for students – the place of study; for children – the name of the children’s institution; for the disabled – gender and group

disability, disabled veteran of the Great Patriotic War, yes, no (underline)

6. Who referred the patient Mytishchi Polyclinic No. 3

7. Sent to the hospital for emergency indications: yes , no, hours after the onset of the disease, injury was hospitalized in a planned manner (underline)

8. Medical diagnosis: the main disease is focal pneumonia of the lower lobe of the right lung

9. No comorbidities

10. Complications uncomplicated

11. Nursing diagnosis shortness of breath, chest pain, pyretic fever

ka, paroxysmal cough, general weakness, feeling of discomfort.

Subjective examination:

1. Reasons for referral: Shortness of breath, chest pain, fever 39.5 C, paroxysmal cough

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

3. Since when does he consider himself ill: from 01/01/2012. At the end of December, there was contact with the ORZ in

family.

(In this section, clarify the patient’s condition immediately before the disease: were there any mental trauma, overwork, hypothermia, eating errors, etc.)

The onset of the disease (when and how the first manifestations appeared, their nature): Marks the onset of the disease from 01/01/2012, the first manifestations in the form of rhinitis and pharyngitis, there was no fever, the treatment was carried out independently.

Course of the disease: Subsequently, the pain in the throat intensified, moved from the upper respiratory

ways to the lower ones, a dry, irritating cough appeared. Since 01/07/2012, the patient’s condition worsened, a febrile fever of 38-39C appeared. 01/12/2012 when calling the district police officer

doctor during auscultation of the lungs, wheezing was detected on the right side, mainly in the lower

parts of her lung. On the radiograph dated 12.01.2012, signs of focal pneumonia were revealed – darkening of the rounded shape in the lower lobe on the right. Sent to hospital for treatment.

(the sequence of manifestation and development of individual symptoms, the period of exacerbation and remission. Research and methods of treatment, deterioration, diagnosis, etc.)

Complaints at the moment: pain in the chest, hard breathing, shortness of breath (dyspnea of mixed type), dry paroxysmal cough, pyretic fever 39.5 C, general weakness. __________________

Life story:

– conditions in which he grew and developed: favorable

– working conditions, prof. harmfulness: normal

– environment: normal

4. Past diseases and operations: chronic gastritis, chronic colitis,

right tubectomy

5. Allergy history: none

(drug tolerance, household allergens, the nature of the allergic reaction: urticaria,

angioedema, vasomotor rhinitis, etc.)

6. Heredity: type II diabetes mellitus, insulin-dependent in 2 generations on the maternal side (mother and grandmother)

(the health and cause of death of parents, brothers, sisters are noted, special attention is paid to pathology,

relevant to the patient’s disease).

7. Epidemiological history: none

(past infectious diseases: tuberculosis, venereal diseases, blood transfusion, injections, surgical interventions, travel outside the city, contact with infectious patients in the last 6 months).

8. Habitual intoxication: smoking, alcohol, drugs, drugs (underline)

9. Social status (role in the family, financial situation): prosperous (full family, married, 2 children, stable financial situation)

10. Spiritual status (culture, beliefs, entertainment, recreation, moral values):

11. Ability to meet physiological needs: appetite is reduced, sleep is difficult due to shortness of breath and cough; other needs are normal

(appetite, sleep, stool, urination, hearing, vision, memory, attention, stress tolerance)

12. Self-care ability: normal

(general mobility, mobility in bed, ability to eat, use the toilet, prepare food,

injecting, housekeeping, etc.)

13. Interaction with family members: husband Andrey Vladimirovich +7-903-1234567

____________________________________________________________________________ _ (composition of the family, relationship to the family, support of the patient by relatives, yes or no)

Objective examination

one. Assessment of the severity of the condition: satisfactory , moderate, severe (underline)
2. Consciousness: clear , confused, absent (underline)
3. Position in bed: active , passive, forced (underline)
4. Body type Normosthenic, correct
5. Growth cm The weight kg
6. Temperature 39.5С
7. Condition of the skin and mucous membranes:
Colour Hyperemia of the skin of the face with a cyanotic tint of the lips and the circumference of the mouth
skin turgor elastic
humidity moderate
edema No
defects No
(scars, rashes, bedsores, vascular pattern, hairline)
eight. Musculoskeletal system Fine
(deformation of the skeleton, joints, muscle atrophy)
nine. Respiratory system:
voice change (yes, no) There is hoarseness of voice
respiratory rate up to 30
breathing pattern (deep, shallow, rhythmic) Superficial, hard, difficult
character of shortness of breath: expiratory, inspiratory, mixed
cough Dry, hoarse, paroxysmal
the presence and nature of sputum: Not
(purulent, hemorrhagic, serous, frothy, smell)
ten. The cardiovascular system:
pulse (frequency, tension, rhythm, filling, symmetry, deficiency)
Pulse 100 (tachycardia), rhythmic, weak tension and filling, symmetrical
BP (on both arms): left: 80/50 right: 80/50
eleven. The digestive system:
Appetite: not changed, reduced , absent, increased (underline)
Swallowing: normal, difficult (underline)
Removable teeth, dentures: (yes, no) No
Language: lined (yes, no) Dry and coated
Stomach: Bloating due to flatulence
(participation in the act of breathing, shape, symmetry, features of the skin of the abdomen, increase in volume)
Chair: There is stool retention
formalized, constipation, diarrhea, incontinence (impurities: mucus, blood, pus)
12. Urinary system:
urination: free , difficult, painful, frequent
urine color: normal , changed (hematuria, “beer”, “meat slops”)
transparency (yes, no) Yes
thirteen. Endocrine system: Fine
(visible enlargement of the thyroid gland)
fourteen. Nervous system: mental state: adequate
autonomic nervous system: Moderate flushing of the skin of the face with a cyanotic tint of the lips and mouth circumference
(blanching of the skin, redness, sweating, salivation, acrocyanosis)
tremor (yes, no) No
gait disorders (yes, no) No
paresis, paralysis (yes, no) No

Data from laboratory and instrumental studies

Complete blood count dated 01/13/2012 Urinalysis dated 01/13/2012

Hemoglobin 125 g/l Specific gravity 1016

Erythrocytes 4.39 million/µl Color light yellow

Platelets 211 thousand/µl Transparency full

Leukocytes 20 thousand/µl Acid reaction

Rod neutroph. 25% No protein

Segm.neutroph. 55% No glucose

Neutrophils (total) 80% No ketone bodies

Lymphocytes 19% Leukocytes 1-3 in the field of view

Monocytes 11% Erythrocytes 1-2 per field of view

Eosinophils 2% Oxalate salts singly

Basophils 0%

ESR 28 mm/h

X-ray studies

Rg of the chest dated 12/01/2012 – on a survey radiograph of the chest organs in the lower lobe on the right, a rounded area of blackout.

Instrumental Research

Endoscopy

ultrasound

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