Sample response template.

1. The sources of primary information for the sister are the case history and the conversation with the patient in accordance with the accepted model of the nursing process, in this case, the model of W. Henderson.

The patient’s needs are violated: to eat, sleep, ensure his safety, work, know how to improve his health.

2.

No. Problem Target Interventions Periodicity
one. Lack of necessary information about the disease. There is no lack of information. Conduct a series of conversations with the patient: – about the main causes and course of peptic ulcer; – about possible complications in the absence of proper treatment; – about the basic principles of treatment of the disease; Why is bed rest important? – about the features of the drinking regime and nutrition; – about the importance of breathing exercises and other exercises to relieve internal tension. – about the importance of monitoring the color of feces and vomit. Daily until you reach your goal.
2. Has no information about the essence of the treatment. Has the necessary information. 1. Conduct a series of short conversations, explaining the effect that each of the prescribed drugs has. Daily until you reach your goal.
3. He does not know ways of non-drug correction of sleep. Knows ways of non-drug correction of sleep. 2. Teach simple breathing exercises. Conducive to relaxation. 3. Teach techniques to relieve anxiety and promote sleep. Daily until you reach your goal.

3. The student demonstrates the ability to competently, easily, reasonably explain to the patient the rules of preparation and the course of research (esophagogastroduodenoscopy, gastric probing), talks about the expected sensations during the research (the presence of nausea, the urge to vomit).

4. The student demonstrates on the phantom the technique of fractional gastric sounding in accordance with the algorithm of action.

TASK 5

Patient V., 40 years old, was admitted to the cardiology department of the regional hospital on the referral of a general practitioner with a diagnosis of rheumatic stenosis of the left mitral orifice in the stage of decompensation. NC IIB (circulatory failure)”.

Carrying out the initial assessment of the patient’s condition, the sister revealed: complaints of constant shortness of breath, swelling in the legs and lower back. The chair is absent for the third day. The patient is concerned about her condition. The patient will be visited by her daughter and mother. They are interested in what products can be brought.

Objectively: the pulse is 100 per minute, satisfactory filling. BP 110/80 mm Hg. Art. The number of breaths is 26 in 1 minute.

From the appointment list:

1. Bed rest.

2. Diet 10.

3. Hypertonic enema every other day.

Tasks:

1. Perform an initial nursing assessment and identify the patient’s compromised needs.

2. Identify problems, set goals, and create a plan to solve problems.

3. Explain to the patient and her relatives the essence of diet No. 10. Explain the features of the drinking regimen.

4. Demonstrate the technique of setting a hypertonic enema on the model.

Sample response template:

1. The patient’s needs are violated: maintain personal hygiene, dress, undress, drink, work, avoid danger.

2.

No. Problem Target Interventions Periodicity
one. Lack of self care. The lack of self-service compensated. 1. Provide the necessary assistance in the implementation of hygiene measures. 2. Provide the necessary assistance in eating. 3. Provide the necessary assistance in dressing and undressing. Daily as needed.
2. Lack of information about nutrition and drinking regimen. There is no lack of information. Conduct an explanatory conversation about the drinking regime, water balance and nutritional habits. Daily control of transfers during the first week of stay in the department.
3. The risk of developing trophic ulcers. There will be no trophic ulcers. 1. Give a high position to the Fowler. 2. Explain why you should not put your feet on the floor. Daily.

4. The student demonstrates the process of explaining to the patient and her relatives the features of diet No. 10.

5. A student demonstrates the technique of setting a hypertonic enema on a model according to the manipulation algorithm.

TASK 6

Patient I., 45 years old, was hospitalized in an anti-tuberculosis dispensary with a diagnosis of “Infiltrative pulmonary tuberculosis for the first time.”

Carrying out the initial assessment of the patient’s condition, the sister revealed: complaints of severe general weakness, decreased efficiency, slight cough with sputum, fever for subfebrile numbers in the evenings for 2-3 weeks, severe sweating at night, shortness of breath. Smokes. There is no specific information about the dangers of smoking. A few years ago I tried to quit smoking all at once. Smoked again a week later.

I would like to know as much as possible about pulmonary tuberculosis.

Objectively: the patient’s condition is moderate, the skin is pale, the eyes are shiny. Subcutaneous fat is poorly developed, temperature 37.3 degrees, respiratory rate 22 per minute, pulse 88 per minute, satisfactory quality, blood pressure 110/70 mm Hg.

The patient is contact, feels a sense of fear about the outcome of the disease.

From the appointment list:

1. Ward mode.

2. Sputum analysis for BC.

3. Blood test for biochemical research.

Tasks:

1. Perform an initial nursing assessment and identify the patient’s compromised needs.

1. Identify problems, set goals, make a plan for solving problems.

2. Explain to the patient the rules for collecting sputum for Koch bacteria.

3. Demonstrate the technique of taking blood from a vein for biochemical analysis on a model.

Sample response template:

1. The sources of primary information for the sister are the case history and the conversation with the patient in accordance with the accepted model of the nursing process, in this case, the model of W. Henderson.

The patient has impaired satisfaction of needs: in breathing, nutrition, maintaining normal body temperature, work, sleep.

one.

No. Problem Target Interventions Periodicity
one. Lack of necessary information about the disease. There is no lack of information. Conduct a series of conversations with the patient: – about the main causes and course of pulmonary tuberculosis; – about possible complications in the absence of proper treatment; – about the basic principles of treatment of the disease; Why is bed rest important? – about the features of the disinfection regime; about the importance of good nutrition. – on the importance of observing the color of sputum. Daily until effect is achieved.
2. Lack of specific information about the harmful effects of tobacco smoke on the lungs and other organs. Has the necessary information. Conduct a series of conversations about the harmful effects of smoking: 1. The effect of smoking on the respiratory system. 2. Effect of smoking on immunity. 3 The effect of smoking on erection. 4. The effect of smoking on the brain. Daily until you reach your goal.
3. Does not know alternative ways to stop smoking. Knows alternative ways to stop smoking. 1. Conduct a series of conversations about the small steps program. 2. List other methods. Daily until you reach your goal.

3. The student will competently and clearly explain to the patient how to pass sputum on the VC.

4. A student demonstrates the technique of taking blood for a biochemical study.

TASK 7

Patient G., 35 years old, was transferred to the pulmonology department with a diagnosis of community-acquired lobar pneumonia of the lower lobe of the right lung. Severe flow. Right-sided exudative pleurisy. Respiratory insufficiency of the second degree”.

Carrying out the initial assessment of the patient’s condition, the sister revealed: complaints of weakness, headache, cough, shortness of breath with little physical exertion, chills, dull pain in the right side of the chest, aggravated by coughing and breathing, pouring sweats. No appetite, thirsty. The patient is afraid that as a result of an error during the puncture, she may be paralyzed or die from bleeding. The patient’s mother would like to know what is the best way to feed and water her daughter.

Objectively: consciousness is clear, the patient is in contact, her condition is grave, she is in a forced position, the skin and visible mucous membranes are pale, the lymph nodes are not enlarged. The temperature is 39.2 degrees, the fever is hectic. NPV – 28 per minute, pulse 110 beats per minute, satisfactory quality, blood pressure 120/80 mm Hg.

From the appointment list:

1. Bed rest, strict.

2. Diet number 10.

3. Sputum analysis for microflora and sensitivity to antibiotics.

Tasks

1. Perform an initial nursing assessment and identify the patient’s compromised needs.

1. Identify problems, set goals, make a plan for solving problems.

2. Teach the patient how to collect sputum for microflora and sensitivity to antibiotics.

4. Demonstrate with the help of an extra the technique of changing underwear and bed linen.

Sample response template:

1. The sources of primary information for the sister are the case history and the conversation with the patient in accordance with the accepted model of the nursing process, in this case, the model of W. Henderson.

The patient’s needs are disturbed: to breathe, to maintain a normal body temperature, to work, to avoid danger, to exercise personal hygiene, to change clothes, to move.

2.

No. Problem Target Interventions Periodicity
one. Lack of information about pleural puncture. The deficit has been compensated. Tell about the features of the preparation, conduct of pleural puncture and the patient’s regimen after it. Once.
2. Lack of self care. The lack of self-service is compensated. 1. Provide the necessary assistance in changing bed and bed linen. Provide assistance when eating. 2. Provide the necessary assistance in dressing and undressing. Daily as needed.
3. Lack of information about the nature of nutrition and drinking regimen with fever. The deficit has been compensated. Conduct an explanation. conversation. Once, followed by control of the amount of fluid drunk.

4. The student explains the rules for collecting sputum for microflora and sensitivity to antibiotics.

5. The student demonstrates the technique of changing underwear and bed linen.

TASK 8

Patient M., 32 years old, was referred by the polyclinic to the pulmonology department with a diagnosis of “bronchial asthma, moderate course.”

Carrying out the initial assessment of the patient’s condition, the sister revealed: complaints of periodic attacks of suffocation, shortness of breath with difficulty exhaling, an unproductive paroxysmal cough with separation of thick, glassy sputum at the end of an attack, weakness, dizziness.

The patient would like to know more about his disease in order to assist in the fight against it. I bought a peak flow meter, but I don’t know how to use it. The nurse also found out that the patient does not use the pocket inhaler correctly, which significantly reduces the effectiveness of the outpatient treatment.

Objectively: the state of moderate severity, the skin is clean, pale. NPV 22 per minute, pulse 86 per minute, satisfactory quality, blood pressure 130/90 mm Hg.

From the appointment list:

1. Ward mode.

Tasks:

1. Perform an initial nursing assessment and identify the patient’s compromised needs.

1. Identify problems, set goals, make a plan for solving problems.

2. Teach the patient the principles of self-observation and the use of a pocket inhaler.

3. Demonstrate the technique of intravenous drip injection of 10 ml of a 2.4% solution of eufillin on the model.

Sample response template:

1. The sources of primary information for the sister are the case history and the conversation with the patient in accordance with the accepted model of the nursing process, in this case, the model of W. Henderson.

The patient’s needs are violated: to breathe, to feel safe, to work, to acquire new knowledge to improve health.

2.

No. Problem Target Interventions Periodicity
one. Lack of information about the disease self-observation. The deficit has been compensated. Conduct a series of conversations with the patient: – about the main causes and course of bronchial asthma; – about possible complications in the absence of proper treatment; – about the basic principles of treatment of the disease; Why is it important to keep a diary of self-observation? – about the importance of a peak flow meter in self-observation, – about how best to avoid a provocateur of seizures and how to act when contact is inevitable. Daily until you reach your goal.
2. The patient does not know the methods of breathing exercises and does not know how to use them. The patient knows the methods of breathing. gymnastics and knows how to use. The instructor of exercise therapy invited by the sister introduces and teaches the methods of breathing exercises. Control before release.
3. Doesn’t know how to use a pocket inhaler. Knows how to use the Pocket Inhaler. Teach the patient how to use the device. Until the goal is reached.

3. The student demonstrates the process of teaching the patient how to use a pocket inhaler.

4. The student demonstrates on the model the technique of intravenous administration of aminophylline according to the manipulation algorithm.

Task 9

A 46-year-old patient was admitted to the hematology department with a preliminary diagnosis of “Acute leukemia” in order to clarify it.

Carrying out the initial assessment of the patient’s condition, the sister revealed: complaints of fatigue, weight loss, fever, a tendency to subcutaneous hemorrhages, pain in the mouth and throat.

In her spare time she likes to read and watch TV. Going to the hospital, I forgot my glasses at home.

Objectively: state of moderate severity, body temperature 38.3 degrees. C, pale skin, multiple small subcutaneous hemorrhages on the extremities, hyperemic mucosa of the mouth and pharynx, ulceration on the gums, purulent plaque on the tonsils, pulse 110 beats. in min. satisfactory qualities, blood pressure 120/80 mm Hg. Art., NPV 20 min.

From the appointment list:

1. Ward mode.

2. Hemodez 400 ml IV drip.

Tasks.

1. Perform an initial nursing assessment and identify the patient’s compromised needs.

2. Identify problems, set goals, make a plan for solving problems.

1. Educate the patient about oral care.

2. Fill the drip system.

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