NHAN DINH THl/C THE
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m m c n e u
1. Neu diidc cac yeu cau cua viec nhg,n dinh thiic the ngiicfi benh.
2. M6 ta diidc cac cdng vi4c can phai lam khi thiic hien quy trinh ky thuat nhan
dinh thiic thi ngiicfi binh.
1. CAC YEU CAU NHAN DINH THLfC THE N G l/d l BENH
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i) 9 N
Khai niem: nhan dinh thtfc the la quy trinh tong quat bao gom cac noi
dung: khai thac tien sut, benh sii va kham thtfc the ngtfdi benh. Qua do ngtfdi
dieu dtfSng ltfdng gia cac duf lieu thu thap dtfdc ttf mot ca the va dtfa ra chan
doan ch&m soc co gia tri ve stfc khoe de lap ke hoach cham soc.
Nhan dinh thtfc the ngtfdi benh la mot cong viec khong the thieu trong
qua trinh ch&m soc ngtfdi benh cua ngtfcJi dieu dtfdng. Nhan dinh thtfc the
ngtfdi benh tot phai dat dtfdc cac yeu cau sau.
- Khoa hoc: ngoai kien thtfc y hoc ma tat nhien moi dieu dtfdng bat buoc
phai co day du, con can phai co mot quan niem bien chtfng con ngtfdi la
mot khoi thong nhat trong do moi bo phan deu co lien quan htfu cd vdi
nhau, do do khong chi nhan dinh thtfc the ddn doc mot bo phan co benh
ma luon luon phai nhan dinh thtfc the toan bo cd the.
- Ky thuat: khi tien hanh nhan dinh thtfc the ngtfdi benh phai theo dung
quy tac va ky thuat nhan dinh chung rieng mdi phat hien dtfdc dung cac
van de dang ton tai d ngtfdi benh hay cac nhu cau ma ngtfdi benh dang
hoac se can co stf ho trd cua ngtfdi dieu dtfdng de giai quyet, vi du: khi
nghe cac tieng khong binh thtfdng d tim, d phoi; khi sd thay gan map me
bd stfdn, hoac khi go phan xa gan thay giam....
- Tam ly: thong qua cach nhan dinh ngtfdi benh ky ltfdng, ty mi ngoai viec
giup dieu dtfdng phat hien dung cac nhu cau cua ngtfdi benh con cung co
long tin cua ngtfdi benh, on dinh ttf ttfdng, giam di stf bi quan lo sd cua
ho, giup ho tin ttfdng vao viec dieu tri, cham soc cua dieu dtfdng va nhan
vien y te, vao stf khoi benh sau nay.
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2. QUY TR iN H KY THU AT NHAN DINH T H l/C THE N G l/6 l BENH
2.1. Chuan bi phong kham benh va dung cu
* Phong kham benh.
- Sach se, thoang khi nhung tranh gio lua.
Am ve mua ret.
- Co du anh sang.
- Kin dao, nhat la nhiing ndi dung de kham benh phu nii.
* Phtfdng tien, dung cu.
Ngoai cac ban ghe can thiet va giiidng de ngiidi benh nam kham, ndi
kham benh can diidc trang bi mot so phiidng tien toi thieu la:
- Ong nghe, can, dong ho co kim giay, nhiet ke, thiidc day.
- May do huyet ap.
- Dung cu de liidi: de kham liidi ngtfdi benh, loa soi mui, soi tai.
- Bua phan xa va kim.
- Gang tay hoac bao ngon tay cao su, bong, dau nhdn (de tham kham trtfc
trang hoac am dao khi can thiet).
- Ddn pin de kiem tra phan xa dong tii.
2.2. D ieu dtfdng
- Can ltfu y den cach an mac: ao quan khong sach (co ao den. mong tay dai.
dau toe roi bii...) se lam giam sii tin ttfdng cua ngiidi benh doi vdi ngiidi
dieu diidng.
- Thai do can phai than mat. niem nd de ngiidi benh de tiep xuc, de tho lo
nhung van de kin dao cua minh. Can tranh nhiing thai do co the lam
ngiidi benh hieu lam la ngtfdi dieu diidng " ban dn” cho ho.
- Khi thiic hien dong tac. can phai co tac phong nhe nhang. ty mi. tranh
tho bao, tranh day trd ngiidi benh nhieu ma khong can thiet nhat la doi
vdi cac ngiidi benh nang. Ngiidi dieu diidng, nhat la dieu diidng nam gidi.
can chu y tdi ban chat e then cua ngiidi phu nut de tranh nhiing cach hoi
va nhat la cach thao tac qua so sang lo lieu, lam ton thiidng den sii tii
trong cua ngiidi benh la phu nii. nhii vay ho se khong noi ra nhiing dieu
can thiet cho chan doan dieu diidng.
- Khi nhan dinh cac van de cua ngiidi benh. can khach quan va than trong:
khong nen co dinh kien triid c. nhat la doi vdi ngiidi benh cu. Can phai
danh gia dung miic cac trieu chiing. nhat la cac trieu chtfng chu quan cua
ngiidi benh: viec nhan dinh, phan tich. danh gia cac trieu chiing do phai
dtfa tren mot cd sd khoa hoc.
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- Phai than trong khi noi vdi ngiidi benh ve tinh trang benh cua ho: noi
chung, phai suy nghi trQdc khi noi de khong noi nhQng van de gi co the
lam cho ho lo sd, hoang mang hoac bi quan vdi benh cua minh; pha; giai
thich de nang dd tinh than, on dinh tii tQcfng cho ho yen tam dieu tri, tin
d sii khoi benh. Doi vdi gia dinh ngiidi benh, chung ta co the noi that
trong mot pham vi nhat dinh, nghia la tuy theo van de, tuy theo quan he
cua ngiidi do vdi ngiidi benh.
2.3. C hu an bi ngQdi benh
- NgQdi benh can dQdc kham d mot tQ the thoai mai, neu tinh trang sQc
khoe cho cua ho cho phep.
- Phai boc lo cac vung can phai nhan dinh.
+ NgQdi benh nam gidi chi nen mac mot quan lot, neu ndi kham benh
dam bao dQdc am ap day du.
+ NgQdi benh nQ gidi nen boc lo tQng phan: ngQc, bung roi cac chi...
- Ve mua ret, can chu y nhac ngQdi benh thao bo khan quang co vi khan do
co the che dau mot so van de rat quan trong d co: bQdu giap, cac tinh
mach co noi, cac seo hach co,.,
2.4. Ky th u a t tien hanh
2.4.1. Khai thac tien sit, benh sit (lich sit benh)
- Phong va'n: khi hoi benh, can dung nhQng tQ d i hieu, tranh dung nhQng
danh tQ y hoc ma ngQdi benh kho biet (hoang dam, huyet m eu ...). Can
nhan nai khai thac cac trieu chQng chu quan cua ngQoi benh, neu can thi
khong nen ngan ngai hoi di hoi lai hoac thay doi cach hoi de co the nam
het y cua ngQdi benh.
- Xac dinh van de chinh cua benh: la ly do da buoc ngQdi benh tim den cd
sd y te (thtfdng la mot trieu chQng hoac mot dieu gi do ngiidi benh cam
thay). Vi vay ngiidi dieu dQdng phai biet khai thac.
+ Khdi dau: van de do bat dau tQ khi nao?
+ Thdi gian: van de do co trong thdi gian bao lau?
+ Vi tri: van de sQc khoe co d dau?
+ MQc do nghiem trong?
+ Yeu to'lam tang (khi thay doi tQ the dau tang- an no bi dau....)
+ Yeu to' lam giam: cac bien phap gi lam thuyen giam benh (dung thuoc,
nghi ngdi, nhin an...)
+ Dieu tri trQdc day: ngQdi benh da dQdc dieu tri nhQ the nao?
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- Xac dinh cac van de ngoai benh.
+ Di dng thuoc hoac thiic an0
+ Tiem phong9
+ Cac benh man ti'nh?
+ Tien sii san khoa (neu la phu nO)?
+ Phau thuat hoac cac tai nan triidc day°
- Tien sii gia dinh:
Ong - ba, Bo - me, anh chi em ruot co ai mac benh nhu ngiidi benh
khong? Van de nay rat quan trong lien quan den mot so benh di truyen qua
cac the he (tieu diidng, due thuy tinh the....)
- Nhan thiic xa hoi:
Giup ngiidi kham hieu diidc hoan canh gia dinh, hoan canh kinh te,
trinh do hoc van, ton giao, cac thoi quen (hut thuoc, uong rtfdu, uong che, tAp
the due, an kieng mot so loai thiic an...).
- Moi triidng dan ctf ngiidi benh sinh song.
Dieu nay rat can thiet vi no lien quan den v£n de dich te (sot xuat huyet,
cum, viem diidng ho hap cap....).
2.4.2. Kham thuc the
Khi tien hanh kham thiic the ngtfdi benh, ngtfdi dieu diidng stf dung cac
ky nang:
- Nhin: quan sat ngiidi benh diidc tien hanh tii phia triidc ra phi'a sau. tu
dau den chan, sii can xiing gida cac bo phan cua cd the....cu the.
- Sd: sd la nhiing kv thuat lien quan den viec sii dung hai ban tay de an.
nan, sd len cac bo phan cua cd the ngiidi benh. Sd danh gia dupe: nhiet do
(nong, lanh), do am cua da. miic do dan hoi cua da, mach. phan ling dau
cua bo phan cd the ngiidi benh. rung thanh. hach. va khoi u.
- Go: la sii dung cac ngon tay hoac hai ban tay de go lam phat ra cac am
thanh tren be mat da de xac dinh vi tri, kich thiidc, do dac, do rong cua
cac to chiic diidi ndi g5: xac dinh vung due cua tim, ganr xac dinh am
vang cua phoi, da day... Co 5 loai am vang khac nhau khi go:
+ Am vang: am cao giong nhii tieng trong, am nav thiidng nghe khi go
tren vung da day.
+ Am due: am nay thiidng nghe tren vung tim, vung gan.
+ Am tram: am nay thiidng nghe diidc khi go len cac khoi u
+ Am cong hiidng trung binh: tieng nhu go ong am vang thiidng nghe
khi go tren vung phoi d trang thai binh thiidng.
+ Am cong hiidng to: nghe diidc khi go len vung phoi co tran khi.
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- Nghe: la dung ong nghe de nghe cac am do cac cd quan trong cd the phat
ra(nghe cac o van tim, nghe phoi, da day, ruot, cac mach mau ldn...).
2.4.2.1. Kham toan than
- Nhan dinh dang di, cach nam cua ngtfdi benh.
- Ngay khi tiep xuc vdi ngtfdi benh, can phai chu y den mot vai cach nam,
dtfng va cach di dac biet cua ngtfdi benh giup gdi y cho chung ta htfdng
tdi mot so nhu cau dac biet cua ngtfdi benh can phai chu y giai quyet de
giup ho dtfdc thoai mai.
+ Ttf the nam “co sung”: quay mat vao phia toi cua nhiing ngtfdi benh
mang nao, dang muon ne tranh nhiing kich thich ve anh sang.
+ Ttf the nam cao dau hoac ntf a nSm ntfa ngoi (ttf the Fowler) cua nhiing
ngtfdi benh dang gap kho khan ve thd.
+ Cach di ctfng dd, toan than nhtf mot khuc go cua ngtfdi benh dang co
nhiing trd ngai ve van dong.
+ Dang di vtfa di vita dm ha stfdn phai cua nhiing ngtfdi benh dang co
nhiing dau ddn vung bung.
- Tinh trang tinh than cua ngtfdi benh: can de y xem ngtfdi benh d trong
tinh trang nao sau day:
+ Tinh tao: ngtfdi benh co the ttf khai thac benh dtfdc, nhan dinh va tra
ldi dtfdc ro rang cac cau hoi cua thay thuoc.
+ Me sang: ngtfdi benh khong nhan dinh dtfdc va khong tra ldi dtfdc dung
cac cau hoi. Khong nhiing the ngtfdi benh con d trong tinh trang hot
hoang. noi lam nham, tham chi' co khi chav hoac dap pha lung tung.
- Hon me: ngudi benh khong co kha nang ttf nhan dinh dtfdc va cung
khong tra ldi dtfdc cau hoi cua dieu dtfdng. Ngtfdi benh khong hot hoang,
khong noi lam nham, trai lai mat lien he nhieu hay it vdi ngoai canh,
tham chi trong trtfdng hdp hon me sau:
+ Ngtfdi benh khong biet dau khi cau veo.
+ Khong nuot dtfdc khi ta do ntfdc vao mom.
+ Mat phan xa giac mac.
- Hon me la do mot trang thai benh nang, hau qua cua rat nhieu benh
nhiem khuan, nhiem doc va cua rat nhieu bo phan, can kham va hoi ky
mdi phat hien dtfdc nguyen nhan cua no.
- Hinh dang noi chung:
+ Gay (suy dinh dtfdng): mat hoc hac, ma hop lai, xtfdng mat loi, nhat la
xtfdng go ma, xtfdng stfdn, xtfdng ba vai noi ro, bung lep, da bung nhan
nheo, so' can nang dtfdi so' can trung binh 20%. Ngtfdi benh gay hay
gap trong cac trtfdng hdp:
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