Download Brief Report consist of :

** Brief Report consist of :
-Name .
- Sex .
- Age .
- Date of admission .
- Department "as: admitted to our department due to--------- .
- Treatment before admission .
- Final diagnosis .
- Past medical history(previous hospitalization , previous chronic disease , allergy ) .
- Changes of cases .
- Specific nursing notes.
- Medication .
- Present of operation or not .
- Diet type .
- Lab. test .
- Prognosis .
* Health: a state of complete physical , mental , and social well being not merely the absence of disease
or infirmity .
* Nursing: the diagnosis and treatment of human responses to actual or potential health problems .
** Nursing Notes for referred Pt. :(Example)
Referral case from surgical department of shefa hospital walking by assistance , male Pt ,70 years old ,
hypertensive & diabetic Pt , bed making was done , v/s were taken and recorded , old dressing on Rt. big
toe was removed , the old dsg wet with blood , new dsg was applied after cleaning the wound with N/S ,
has cannula fixed in Lt fore arm and no signs of inflammation in place ---------- .
** Nursing Notes when prepare Pt. for operation :(Example)
Pt. Conscious , oriented to x3 , v/s were taken and recorded , prepared for the operation , kept NPO from
midnight , shaving is done at the operation site , Lab investigation ready , x-ray ready , and the Pt is ready
for the operation -------- .
** Surgical classification:
1- Diagnostic: surgery done to confirm dx (biopsy) .
2- Curative: surgery done to treat the pt.(appendectomy) .
3- Reparative: surgery done when multiple wounds must repaired .
4- Reconstructive: surgery done to correct some thing (cosmetic surgery) .
5- Palliative: surgery which treat s&s of disease , but it doesn't treat the disease it self .
** Surgical classification according to the degree of urgency :
a- Optional: surgery is scheduled at the preference of the pt. (cosmetic surgery) .
b- Elective: the approximate time for surgery is at the convenience for the pt. (superficial) .
c- Required: surgery required within few weeks(cataracts) .
d- Urgent: surgery required within 24-48 hours(cancer) .
e- Emergency: surgery should done immediately (Intestinal obstruction) .
**Types of solutions:
1- Crystalloid solutions: water and other uniformly dissolved crystals , such as salt & sugar .
2- Colloid solutions: water and molecules of suspended substances , such as blood cell , and blood
products such as albumin .
1- Crystalloid solutions are classified as:
A- Isotonic solutions :- one that contains the same concentration of dissolved substances as normally
found in plasma .
- Is generally administered to maintain fluid balance in pts who may not be able to eat or drink for a short
period of time .
- Examples: 0.9% Saline (also called normal saline) , 5% dextrose and water (also called D5W) , Lactate
Ringers .
B- Hypotonic solutions:- one that contains fewer dissolved substances than normally found in plasma .
-Is administered to pts with fluid losses in excess of fluid intake , such as those who have diarrhea or
vomiting .
- Examples: 0.45% sodium chloride (also called half-strength saline) , 5% dextrose in 45% saline .
C- Hypertonic solutions:- one that is more concentrated than body fluid .
- Draws cellular and interstitial water into the intravascular compartment .
- Hypotonic solutions are not used very frequently , except in extreme cases where it is necessary to
reduce cerebral edema or expand the circulatory volume rapidly .
- Examples: 10% dextrose in water (also called D10W) , 3% saline , 20% dextrose in water .
2- Colloids solutions:- Are used to replace circulating blood volume .
- Examples: blood , blood products , and solutions known as plasma expanded .
* MEDICATION ADMINISTRATION:
MEDICATIONS ARE GIVEN ACCORDING TO THE “FIVE RIGHTS”:
1. Right patient
2. Right drug
3. Right dose
4. Right time
5. Right route
“Right documentation” is sometimes referred to as the “sixth right.”
* Medications Are Checked at Least Three Times According to the Five Rights:
1. When the medication container is removed from storage .
2. When the medication dose is removed from the container .
3. Before returning the medication container to storage .
* Common Routes of Medication Administration:
1. PO: by mouth
2. Sublingual: under the tongue
3. Topical: on the skin
4. Subcutaneous: into adipose tissue (usually given at a 45-degree angle, with a 1/2- to 1-inch–long
needle)
5. Intramuscular: into the muscle (given at a 90-degree angle, with a needle long enough to pass through
adipose tissue and enter the muscle)
6. Intravenous: into the vein
7. Rectal: into the rectum
8. Intrathecal: into the spinal canal (not usually administered by nurse)
* CALCULATION OF DOSAGES:
Example: The physician has ordered 35 mg of Demerol. On hand you have Demerol 50 mg _ 2 mL
50 mg = 2 mL
35 mg =X mL
50X = 70
X = 1.4 mL
Clinical instructor:
Mohammed EL-Nagy