Nursing rounds-three modes of reporting diseases

Nursing rounds-three modes of reporting diseases

No matter which ward or department you are in, all departments are carrying out their own specialized nursing rounds, which can be described as the normal state in our nursing work. No matter what kind of patients have their own unique nursing quality and effect, patients have nursing problems to solve.

Three modes of reporting illness in nursing rounds

The ward round process is generally presided over by the head nurse of the department. The responsible nurse reports the illness and nursing physical examination, puts forward nursing diagnosis and measures for further discussion, participates in ward rounds or corrects or supplements, interspersed with questions and guidance from superior nurses, and comments on the discussed issues after ward rounds.

Recite: Recite. During nursing rounds, the nurses in charge are really under great pressure, so that some nurses make great efforts to prepare in advance and "recite" the patient's illness report when reporting the medical history.

This kind of "rote learning" illness report can't grasp the key points, let alone the clinical situation, and even sacrifice your precious rest time.

This kind of "reciting" medical history reports often happens to junior nurses. This mode not only makes the listener feel dull, but also makes the reporter "stressed" and preoccupied.

Dialogue: Say it. This report mode is just like the daily communication of nurses, except that the content of the conversation depends on the patient's specific condition. Generally speaking, senior nurses in the department have rich work experience, talk casually and complete the medical history report easily and lightly.

Narration: say it. Describe the patient's condition, treatment and nursing process in narrative form. This model needs a responsible nurse with solid basic skills, good eloquence and rich experience in "pre-examination" to reach this level. It is vivid and flexible, and all participants like it. This is the ideal state that our nurses want to pursue.

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In primary hospitals, most of the patients admitted by various departments of the hospital are common and frequently-occurring diseases, such as upper respiratory tract infection, pneumonia, enteritis and so on. In the clinical front line, many nurses and even head nurses have a vague concept of nursing rounds, and they can't tell what is case rounds and what is difficult case rounds.

Therefore, it is necessary for nursing managers to conduct a special study on clinical nurses to improve the quality of nursing rounds purposefully.

After training and learning, nurses should carefully understand the courseware, understand the categories and significance of nursing rounds, and communicate with teachers, colleagues or nursing managers after training to understand the essence of nursing rounds.

When nursing clinical rounds, nurses can practice and experience, and pay attention to the following points in their work:

Highlight the characteristics of the college

As nurses and nursing managers at all levels, we should abandon the idea of passive response, strictly follow the nursing ward round plan made at the beginning of the month, complete this basic nursing work with good quality and quantity, face up to the problems, and not reject or dislike them.

In nursing management, we can learn from doctors' rounds, highlight the characteristics of undergraduate courses, give priority to guiding and helping to solve clinical practical problems, and let nurses really enjoy the fun of innovative nursing in nursing rounds, increase their knowledge and enhance their skills.

Don't treat rounds as a "show"

Nurses, especially nursing managers at all levels, should not take nursing rounds as a "show" and passively cope. They should make good use of this opportunity: whether it is case rounds, professional rounds or teaching rounds, they should take improving the professional knowledge and skills of junior nurses as the starting point and take responsibility, earnestly implement each round of rounds, embody the purpose of nursing rounds, solve practical nursing problems for patients and guide the clinical nursing work of junior nurses.

The number of wheels can be changed by the machine.

Although hospitals and departments have work plans: 65438 rounds per month +0 ~ 2 rounds, in the actual clinical nursing work, managers don't need to be so rigid and rigid.

There is no limit to the number of nursing rounds per month, which can be done well according to the actual work needs, because the patient's condition is constantly changing and the nursing problems are constantly changing alternately, which determines that nursing rounds can be managed dynamically, and the specific time and number of rounds can not be fixed.

Discuss more and ask fewer questions.

Why are nurses afraid of nursing rounds? Is it true that the previous forms of nursing rounds were so boring and dark all the way, and questions were the main ones every time, which increased the fear and pressure of nurses, so nurses hated rounds?

Strengthen lateral study in the hospital, participate in doctor rounds in other hospitals, and feel the practices and advantages of others. Nurses no longer blindly accept teachers' harsh questions like primary school students, but have the opportunity to ask questions from superior nurses in nursing rounds to increase their knowledge and memory, thus improving the quality and level of nursing.

As a nursing manager and superior nurse, we should have this idea in our minds, make good use of the "golden key" of nursing rounds, constantly open the door for junior nurses to answer questions and improve their professional level and nursing quality.

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