Medicine is full of various specific terms and concepts that are clear only to the medical staff. An ordinary person simply cannot know them all. Therefore, in this article I would like to talk about what a nursing history is.
About the concept
First of all, it is necessary to understand the terms that are dominant in this article. So what is a nursing history? First of all, this is an important medical document, which no one should forget (both the patient and the he alth 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 the stages
As mentioned above, in order to correctly complete the nursing history, the he alth worker must go through five main stages with his patient.
- Collection of information about the patient and his state of he alth. The patient's name, age, gender will be indicated here. As well as data from the examination, laboratory and instrumental studies (ifsuch were carried out).
- The next no less important stage is the formulation and definition of the main problems of the patient (of course, related to he alth).
- The third stage is the competent drawing up of a nursing intervention plan, which is based on the priority of the patient's problems. At the same time, the nurse must also set short-term and long-term goals.
- Fourth stage: implementation of the nursing intervention plan, both as prescribed by the doctor and independently (preparation for research, thermometry, etc.).
- The most important stage: analysis of the patient's response to nursing interventions. In this case, the criteria are both objective (normalization of body temperature, improvement in laboratory tests) and subjective indicators (normalization of sleep, reduction of pain).
Design
It is worth saying that the nursing medical history for therapy (as well as for 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 execution of this document:
- All lines must be filled out in neat, even, readable handwriting.
- Be sure to strictly follow the form in which the nursing history is filled out.
- Formulation should be short and precise, conclusions should be logical.
- The information displayed in the nursing history should be as rich and complete as possible.
- The document must beclean.
After filling out the nursing history of the disease, this document is supported by a folder with other papers relating to a particular patient.
Example
In this article, I also want to roughly consider what a nursing medical history for therapy might look like. 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 could be a table of approximately the following format:
| Date | Patient problem | Goal (i.e. expected result) | Nurse action | Frequency of patient assessment | Final target date | Final Nurse Evaluation |
In each box, the nurse must enter full details of what needs to be done and what has been done about the patient. The ultimate goal of this document is to compare the previously set goals and the results of nursing care for the patient. It is worth saying that on the basis of these data, the treatment of the patient by his doctor can even be adjusted.
