Examination of a patient by a nurse
Apr 21, 2018
A patient examination is the collection of information about a patient, which includes patient complaints, a history of the disease, a history of life, an objective examination. An important element in the examination of any patient is the opportunity to question him, to collect information through oral dialogue.
The questioning of the patient includes three main points.
1. Complaints of the patient about the disease with which he came for medical help.
2. History of the disease with which the patient entered the treatment.
3. History of life.
Complaints of the patient. The nurse should collect exactly those complaints that disturb the patient upon admission. This will determine the correctness of the diagnosis, and therefore, directly treatment of the patient. More often the patient is questioned by the attending physician, but in recent years, many clinics have gradually moved to the European model, where the nurse is engaged, which transmits to the attending physician all the data obtained. The questioning is conducted in the ward or in the office, separately from other patients. The voice of the nurse should be calm, smooth, medium loud. Important sensitive, patient attitude to the patient. If it is impossible to interview personally with the patient( the patient is unconscious, inadequate, has a mental illness), then information is obtained from relatives or close people. It is necessary to properly characterize each complaint.
The most common complaint for many surgical diseases is pain. Pain is characterized by the following features: localization( location) and irradiation( where it gives up), time of appearance, duration and intensity. It is important to clarify the relationship of pain to certain factors( for example, physical work, trauma, eating, mental stress).The pain can be combined with a number of symptoms, such as dizziness, loss of consciousness, vomiting, etc. It is necessary to find out whether the pain decreases if the patient has taken some kind of forced position( lying, half sitting, standing).If there is vomiting, you should find out how often it arose, the nature of the vomit, whether it brought relief, what complaints accompanied.
History of the disease( aNamis esis morbi).The purpose of the anamnesis of the disease is to obtain information about the onset and further development of the disease in chronological order. The history of the disease should detail the development of the disease from initial manifestations to the present. It is important to establish how much time has elapsed from the onset of the disease to this patient request for medical care. It is necessary to find out the cause of the disease( trauma, physical activity, chemical factors, heredity, etc.), the symptoms of the manifestation of the disease during the entire period of the development of the disease, their changes, whether the patient asked about his illness for medical help, if so, whenfirst. It is necessary to find out what diagnostic examination it was( laboratory, instrumental), the results of these examinations, what treatment was used before admission, its effectiveness( the patient feels better or worse after the prescribed treatment or his condition has not changed).If the patient can not remember the name of the drugs that he took, then he will take the drugs with him or they will be brought by his relatives. It is necessary to study the patient's medical records: extracts from the medical history, medical certificates of analysis( laboratory tests, X-ray images).
History of life( aNam esis vitae).The history of life is a brief medical biography of the patient. Its purpose is to clarify the relationship between the patient's living conditions and the occurrence and development of the disease.
Anamnesis of life is going according to a certain plan.
1. Birth and development in childhood. If possible, find out the gynecological anamnesis of the mother: how she suffered pregnancy, in what terms she gave birth. It is necessary to find out what diseases the child suffered as a child, physical-motor and mental development in childhood.
2. The transferred diseases during a life( infectious, venereal, tuberculosis, chronic diseases), presence of chronic diseases, their duration of a current and the periods of an exacerbation. An important point in the history of life is the question of previous operations and injuries.
3. Gynecological anamnesis in women: physiology and pathology of the female genital area, anamnesis of pregnancy and the course of childbirth.
4. Work history. The main thing is to find out professional harmful factors at work. Occupational harmful factors include physical and mechanical( vibration, noise, long standing or sitting), chemical( working with chemicals, substances), biological( light, animal hair).
5. Family history. The main task in collecting a family history is information about the diseases of the nearest relatives of the patient( parents).If the parents are dead, then you need to find out the cause of death. It is necessary to determine the presence of known genetic diseases( such as Down's syndrome, hemophilia).
6. Household history. To find out in what conditions the patient lives: the presence of water, heat, sewerage, the amount of free space per person, how personal and household hygiene is observed.
7. The presence of bad habits in the patient: smoking, drinking alcohol, drugs. It is important to clarify how many cigarettes the patient smokes per day, what cigarettes are in the fortress, what alcoholic drinks the patient uses, how many times a week, day and in what quantity. If the patient uses drugs, it is important to find out the type of drug, the duration of use of these drugs.
8. Allergic anamnesis. The nurse must find out if the patient has an allergy. If the patient has had allergic reactions, then it is necessary to find out what exactly. An important point is the allergy to medications. The patient should list all the names of the drugs or a group of drugs that caused an allergic reaction. This will help avoid complications during treatment and at the time of anesthesia.
9. Infection analysis: what infectious diseases a person has suffered throughout his life, whether the patient ever received a blood transfusion.
Objective examination of the patient .An objective method of examination is based on the study of the patient's physical data and includes the evaluation and description of various physical parameters. For each patient, an objective examination is an important step in the general scheme and serves to establish the correct diagnosis and choice of method, type of treatment. With an objective examination, a general examination of the patient and the organ or organ system itself is carried out, with complaints about the work of which the patient sought medical help. Inspection is best done in the presence of natural light, in a warm, ventilated room. The hands of the nurse must be warm, with short-cut nails.
General examination of the patient. During general examination, the person's consciousness, the patient's condition, his general appearance, the condition of the external skin and mucous membranes are determined.
Consciousness of the patient .Consciousness in the patient is clear, confused, may be absent. Violation of consciousness occurs gradually, in several stages: stupor, sopor, coma. When the stupor develops, the patient is disturbed by the orientation in space. The person becomes sluggish, slow and does not immediately answer questions, reduced the overall reaction and local reflexes. When asking a patient in a stupor, you have to ask several times, raise your voice when talking. Sopor is a pathological condition when the patient is strongly inhibited, answers questions only when crying or when the physician brakes him physically, he is as if in hibernation. Reflexes are depressed. Coma is a complete loss of consciousness to the sick. The person does not react to strong external stimuli. Reflexes are depressed or absent.
Situation of the patient. Determination of the patient's position is important in many therapeutic, surgical diseases( for example, in diseases of the spine, pathologies of internal organs).The position of the patient is active, passive, forced. Active - when a person can independently, easily easily change their physical position( stand up, sit down, bend over, raise their arm or leg, etc.).Active position is observed in normal in healthy people or in the presence of a patient with a mild disease, at the beginning of its development. Passive - when a patient is able to perform certain physical actions through force or he can not change his position on his own. This happens with diseases of the spine, in the presence of contractures, with paralysis or paresis, fractures or dislocations, diseases of internal organs. Forced - the patient occupies this position to relieve pain or other pathological discomfort. For example, the patient assumes a forced position in case of suffocation - orthopnea position: the patient sits down to ease the condition, leans forward with an emphasis on the hands. Often, the patient takes a forced situation with heart failure, pleurisy, bronchial asthma. With a fracture of the limb, the patient also takes a forced position, which reduces pain.
Definition of the patient's constitution. The constitution of a person is a type of build. The constitution of the patient, depending on the type of constitution, is asthenic, normostenic, hypersthenic. The asthenic type of constitution is characterized by the predominance of longitudinal dimensions over the transverse: the thorax is narrow, the ribs are obliquely downward, the supraclavicular and subclavian fossa and intercostal spaces are well defined, the scapula is spaced from the thorax, the acute epigastric angle. Hypersthenic physique is characterized by a broad chest with pronounced transverse parameters, epigastric angle is blunt. A person with a hypersthenic physique is well developed muscular mass, he is short, with a short neck and limbs. In a person with a normosthenic physique, all parameters in the body are proportional. The thorax has the form of a cone, the scapula is closely adjacent to the thorax, the epigastric angle of the straight line.
Condition of skin and mucous membranes. Important information about the patient's condition can give the nurse and doctor an examination of the skin and mucous membranes. When examining the skin, the nurse should pay attention to color, purity, temperature, turgor( elasticity), dryness or skin moisture.
Skin, depending on the color, is pale, hyperemic, cyanotic, icteric. Pale skin occurs with anemia( for example, when a person has internal or external bleeding).Skin with a cyanotic shade is observed in patients with cardiac or respiratory failure. With icterus - with liver diseases. Sometimes the skin of patients has a bronze hue, this is noted in diseases of the adrenal glands. With cancer or sepsis( blood infection), the skin becomes gray, with an earthy tinge.
Cleanness of the skin. Various skin eruptions can occur on the skin of a person, for example, spider veins, petechiae, allergic manifestations in the form of urticaria, bruising or bruising. Also important is the presence of changes after injuries, burns, frostbite. The nurse must examine the skin of the entire body of the patient, and not its individual parts. Turgor of the skin provides information on their elasticity. With dehydration, the skin turgor decreases, the elasticity decreases. Wet skin can occur with fever, cardiovascular insufficiency, and dry - with dehydration( with severe vomiting, diarrhea).The examination of the patient is completed by the determination of edema. Edema can be external and internal, local or can spread to the entire body( anasarca).Swelling is more common in diseases of the cardiovascular system or kidney system. Internal oedemas are dangerous, they are more difficult to determine. To determine internal swelling, the intradermal test is used.
Inspection of organs and systems of organs in patients
Inspection of organs and systems of organs in patients by a nurse is carried out with the help of special examination methods. These methods include palpation, percussion, auscultation.Palpation( palpation). Palpation is performed with the fingers of the right and left hands. The hands of the nurse should be warm and dry, the skin smooth, the nails short-cut. Palpation begins away from the place of injury or place of pain, gradually approaching it. Palpation is superficial( palpation of the skin and subcutaneous integument) and deep( feeling of deeper underlying subcutaneous formations: internal organs, lymph nodes).With the help of palpation, a nurse can detect the location, shape, size, swelling, or swelling due to inflammation. An important element of palpation is the examination of peripheral lymph nodes. Palpation of the lymph nodes is carried out in a certain order: first examine the occipital and parotid, then the cervical, submandibular and supraclavicular, axillary, ulnar, inguinal and popliteal. Normally, in a healthy person, lymph nodes that are painless, up to 1 cm in size, are not connected with each other and with adjacent covers, are mobile.
With the help of palpation, a nurse can determine the pulse of a patient. Pulse is determined on the radial artery, brachial artery, femoral artery, popliteal artery, carotid artery. Pulse is characterized by filling, tension, frequency, duration. Palpation of the abdomen is important in the diagnosis of acute diseases( appendicitis, enteritis, intestinal obstruction, acute peritonitis).For palpation of the abdomen, the Obraztsov-Strazhesko method is used. With the help of palpation, a nurse can determine the presence or absence of external edema. When pressing on the skin with a finger in the presence of external edema a depression is formed.
Percussion is an objective method of research of a surgical patient. Percussion is based on the tapping of certain areas of the body and determining the resulting sound of the absence or presence of pathological changes in this organ. Percussion is used to determine the exact parameters of internal organs and / or pathological focus( in the heart, lungs, liver).Percussion of the abdomen is used to detect fluid in the abdominal cavity with ascites.
Auscultation is an objective method of examining a patient, listening to the sounds of a working organ. Auscultation is of two kinds - direct and indirect. Indirect auscultation is carried out through a special device - a stethoscope, and the straight line is carried directly through the ear of the medical worker, which he applies to the patient's body. Auscultation is used to listen to the heart, lungs, hollow organs of the abdominal cavity. With auscultation of the heart determine the frequency, heart rhythms, noise. With auscultation of the lungs, pathological rales, noises are revealed. With auscultation of the intestine, peristaltic noises, their presence or absence are determined.