Throughout the history of the patient's treatment, a certain number of personnel are actively involved. Including nurses. Their task is to fulfill the doctor's appointments and to ensure that the patient takes the necessary medicines. It is especially important to follow all the doctor's instructions when it comes to acute gastritis.
In order not to get confused in diagnoses and prescriptions there is a medical history.
The medical history includes all the basic data needed for further treatment, a patient with acute gastritis. There are: etiology, pathogenesis, clinical picture, treatment, diagnostic methods and much more. Each point of history is necessary, since it includes the individual characteristics of the patient, as well as an individual diagnosis of the set of analyzes.
The main executable actions of the medical history with acute gastritis is a nursing process. It consists of 5 stages that must be observed:
- At the first stage, the patient is entered into the history, his condition is due to the initial examination. Also an important task is to determine the state of health in the light of exacerbation of gastritis.
- The second stage is the diagnosis. Despite the fact that the junior medical staff does not have a doctor's qualification, the nursing process includes the setting of a primary diagnosis, which is then entered in the medical history.
- The third stage is action planning. This process involves the introduction of an action plan for the patient in the medical history. The entered data will be preliminary, not final. The final procedure is confirmed by the doctor.
- After the attending physician has confirmed or changed the diagnosis and the process of treatment, the fourth stage is in use - the nursing plan. The essence of this stage is to implement the plan set by the doctor, in the nursing process.
- The fifth stage is for the doctor and the patient. It is necessary in order to determine the quality of care throughout the treatment.
The nursing process also includes the care of a patient who suffers from acute gastritis. The history of the disease indicates what manipulations were performed on the patient during the treatment.
During the care of the patient, the nurse must explain to the patient the necessary actions on his part for a speedy recovery. In particular, the nursing process includes an explanation of the dangers of smoking and alcohol use. This is especially important if the diagnosis of acute gastritis is in the history of the disease. She also needs to monitor the body weight of the patient, his transfers from relatives. Her duties include preparing a patient with acute gastritis for procedures that are prescribed by the doctor. In particular, preparation for gastroscopy, X-ray examination.
It is also necessary to make all the manipulations made outside the treatment process in the medical history. Namely, bleeding, manipulation before research( such as gastroscopy) and so on.
Clinic
In addition to the diagnosis in the history of the disease, there is a clinic of acute gastritis. The clinical picture is necessary to find out all the individual processes that occur with exacerbation of gastritis in the patient.
In particular, it is necessary to note clinical symptoms: abdominal pain. Which they are - sharp or permanent. In many ways, the clinic will depend on what the patient ate a few hours before the examination. There is nausea or vomiting, heartburn, belching and other symptoms. All these clinical tests are necessary to determine the diagnosis, as well as the form of acute gastritis. In some cases, it is possible that the disease will occur in conjunction with other diseases, which means that the method of treatment and diagnosis will change.
The clinical history of the patient, which he experienced in the first few hours after the onset of an exacerbation of the disease, is also recorded in the medical history. Such data are necessary in order to determine the clinical diagnosis, the type of gastritis: catarrhal, fibrous, corrosive, phlegmonous. This is very important, since the treatment of this disease will be completely different.
Reasons for
Indication of etiology in the history of the disease with exacerbation of gastritis is very important. As this item shows the cause of the disease.
The etiology of the disease can be very different. If it is a question of food, it is worth noting that alcohol consumption, smoking, even banal overeating very much affects the factors of the emergence of acute gastritis.
In the history of the disease, etiological analysis also includes endogenous etiological factors of the onset of acute gastritis. These are factors at the cellular level: mass breakdown of proteins, increase in the blood content of nitrogen, metabolic disorders, kidney and liver( atrophy).
Mechanism of nucleation
In the history of the patient a special role is given to pathogenesis. This item shows how an acute gastritis was obtained.
For example, catarrhal( simple) gastritis. Its pathogenesis is an aggressive effect on the gastric mucosa. Irritants in the formation of acute gastritis can become products such as vinegar or hot pepper. In some cases, this is not a process of digesting food and not mechanical damage. It is possible that the formation of acute gastritis is the onset of an infectious disease.
Pathogenesis in the catarrhal form is considered damage to the mucous membrane of the stomach, which can be caused by a variety of images, including at the cellular level.