Báo cáo thực tập tốt nghiệp chủ đề thực tập tốt nghiệp tại trung tâm y tế thành phố dĩ an

Phụ lục 1

TRƯỜNG CAO ĐẲNG CÔNG NGHỆ CAO ĐỒNG AN
KHOA Y - DƯỢC

BÁO CÁO THỰC TẬP TỐT NGHIỆ̣P
TRÌNH ĐỘ CAO ĐẲ̉NG
NGHỀ ĐIỀU DƯỠNG

Chủ đề:
THỰC TẬP TỐT NGHIỆ̣P TẠI TRUNG TÂM Y TẾ THÀNH
PHỐ DĨ AN

SVTT: Huỳnh Thị Thu Hương
GVHD: Trần Thị Yến
CBHD: Lê Thị Hương

Bình Dương, tháng 05 năm 2023

2061115


Phụ lục 1

LỜI CẢM ƠN
Sau 3 tháng thực tập vừa qua là 3 tháng trọn vẹn nhất trong quãng đời sinh
viên của chúng em. Việc được tiếp thu những bài giảng quý báu của thầy cô,
được biết đến nhiều kiến thức chuyên môn và cả những đạo đức nghề nghiệp
mà thầy cơ truyền tải trong bài giảng. Cùng với đó là 3 tháng thực tập tại Trung
tâm Y tế Thành phố Dĩ an là quãng thời gian quý báu để em có thể vận dụng
những kiến thức mà thầy cơ đã truyền dạy cho em trong suốt 3 năm vừa qua,

em đã được các anh chị trong Trung tâm Y tế Thành phố Dĩ an chia sẻ những
kinh nghiệm quý báu để có thể thực hành những kiến thức đã học vào ngành
nghề của mình một cách thành thạo và nhanh chóng.
Em muốn gửi lời cảm ơn chân thành nhất đến tồn thể q thầy cơ trong
Ban giám hiệu trường Cao Đẳng Công Nghệ Cao Đồng An, các thầy cô đã
giảng dạy môn học và đặc biệt là cô Trần Thị Yến đã dẫn dắt em trong đợt thực
tập tốt nghiệp lần này, để em có thể hồn thành xuất sắc nhất báo cáo thực tập.
Em xin chân thành cảm ơn đến Trung tâm Y tế Thành phố Dĩ an, đã tạo cơ
hội cho em được thử sức, thực tập một cách bài bản nhất những kiến thức mà
em đã được học và vận dụng vào thực tế. Em xin gửi lời cảm ơn đến các anh
chị Lê Thị Hương đã phụ trách quản lý em trong suốt thời gian thực tập và tồn
thể các anh chị trong cơng ty đã giúp đỡ em trong thời gian vừa qua.
Qua thời gian thực tập chúng em viết báo cáo này để tóm tắt q trình thực
tập tại trung tâm y tế thị xã Thuận An. Trong quá trình làm bài báo cáo chúng
em khơng tránh khỏi những thiếu sót, chúng em rất mong được sự góp ý xây
dựng của quý thầy cơ để bài báo cáo của chúng em được hồn thiện hơn.
Em xin chân thành cảm ơn!


Phụ lục 1

NHẬN XÉT CỦA GIẢNG VIÊN HƯỚNG DẪN
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Đánh giá về Báo cáo thực tập tốt nghiệp: …….. /10 điểm
Bình Dương, ngày…..…tháng…..….năm…..
…

GIẢNG VIÊN HƯỚNG DẪN
(ký và ghi rõ họ tên)

LỜI PHẢN BIỆ̣N CỦA GIẢNG VIÊN HƯỚNG DẪN


Phụ lục 1

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Đánh giá về Báo cáo thực tập tốt nghiệp: …….. /10 điểm
Bình Dương, ngày…..…tháng…..….năm…..
…
GIẢNG VIÊN HƯỚNG DẪN
(ký và ghi rõ họ tên)


Phụ lục 1

MỤC LỤC
Chương 1. TỔNG QUAN VỀ TRUNG TÂM Y TẾ TP DĨ AN.............
1. Lịch sử hình thành và phát triển Trung tâm Y tế..................................


Phụ lục 1

CHƯƠNG 1. TỔNG QUAN VỀ TRUNG TÂM Y TẾ THÀNH PHỐ

DĨ AN
1.

Lịch sử hình thành và phát triển của Trung tâm Y tế

1.1.

Thông tin chung
Tên cơ quan quản lý trực tiếp: Sở Y tế Tỉnh Bình Dương.
Địa chỉ: Số 500 Đường D9T743, KP. Đông Tác, P. Tân Đông Hiệp,

TP. Dĩ An, T. Bình Dương.
Điện thoại: 0274.3 742 902

FAX: 0274.3 731582

Huyện Dĩ An được tái lập từ tháng 9/1999 trên cơ sở chia tách huyện
Thuận An thành hai huyện Thuận An và Dĩ An. Là huyện nằm ở cực Nam
của tỉnh Bình Dương, phía Đơng giáp quận 9 (TP.HCM), phía Tây giáp
huyện Thuận An (tỉnh Bình Dương), phía Nam giáp quận Thủ Đức
(TP.HCM), phía Bắc giáp Thành phố Biên Hồ (Phường Hố An, tỉnh Đồng
Nai).
Cùng với việc tái lập huyện Dĩ An tháng 9 năm 1999, Trung tâm Y tế
huyện ra đời. Thời gian này do chưa có trụ sở nên đơn vị phải sử dụng nhờ
trụ sở của Trạm Y tế Tân Đông Hiệp bằng cách dựng nhà tiền chế. Nhân sự
gồm có 3 Bác sĩ, 4 Hộ sinh, 4 Y sỹ, 1 Dược tá. Mặc dù khó khăn nhưng tập
thể đơn vị vẫn cố gắng hoàn thành tốt mọi nhiệm vụ được giao.
Đến tháng 10/2004 Trung tâm Y tế huyện được chuyển đến cơ sở mới,
thời gian này trang thiết bị bổ sung tương đối đầy đủ. Hoạt động tốt hơn, đã
thu hút được một lượng bệnh nhân khá đông đảo và ngày càng tạo thêm

niềm tin cho nhân dân.
Tháng 10/2005 Trung tâm Y tế được tách thành Bệnh Viện đa khoa
huyện Dĩ An và Trung tâm Y tế dự phòng huyện Dĩ An. Theo quyết định số
133/2005/QĐ-UBND ngày 19/7/2005 của UBND tỉnh Bình Dương về việc
tổ chức lại Trung tâm Y tế huyện, thị, hai đơn vị trực thuộc Sở Y tế tỉnh
Bình Dương quản lý.


Phụ lục 1

Đến năm 2013 Trung tâm Y tế thị xã Dĩ An được thành lập theo Quyết
định số 16/QĐ-UBND ngày 03 tháng 01 năm 2013 của UBND tỉnh Bình
Dương trên cơ sở hợp nhất 03 đơn vị sự nghiệp trực thuộc Sở Y tế gồm
Bệnh viện Đa khoa, Trung tâm Y tế và Trung tâm Dân số - Kế hoạch hóa
gia đình.

Hình 1. Trung Tâm Y tế Thành phố Dĩ
An Tổng số cán bộ công nhân viên:


Phụ lục 1

KẾ HOẠCH CHĂM SÓC BỆ̣NH NHÂN
KHOA CẤP CỨU - HỒ̀I SỨC TÍCH CỰC VÀ CHỐNG ĐỘC TTYT DĨ AN

CHĂM SÓC BỆ̣NH NHÂN TĂNG HUYẾT ÁP
PHẦN I: THU THẬP DỮ KIỆN
I. Hanh chanh:
Họ tên bệnh nhân: NGUYỄN TẤN PHÁT
tính: Nam

Dân tộc: Kinh

Sinh năm: 1951

Giới

Nghề nghiệp: Hưu và <60 tuổi

Quốc tịch: Việt Nam

Địa Chỉ: Đông Chiêu - Tân Đông Hiệp - Dĩ An - Bình Dương
BHYT: có

Số thẻ BH: BT 2 74 7423126626 74028

Họ tên, địa chỉ người nhà: Nguyễn Hoàng Huynh ( cháu )
Điện thoại số: 0979601522
Đến khám bệnh lúc: 23 giờ 10 phút, ngày 26 tháng 03 năm 2023

II. Lý do nhập viện: Tăng huyết áp
III. Hỏi bệnh
1.

Bệnh sử: Tiền sử tăng huyết áp tối cùng ngày nhập viện bệnh ở nhà thấy mệt kèm

chóng mặt khơng sử trí gì được người nhà chở vào TTYT xử trí - nhập viện
2.

Tiền sử:
Cá nhân: Tăng huyết áp 10 năm



Thói quen:


Phụ lục 1



Tiền sử dị ứng thuốc và thức ăn: khơng



Hút thuốc lá, khơng uống rượu bia: khơng.



Ăn uống bình thường



Bệnh lí:
Gia đình: khơng ai có bệnh tim và bệnh lí mãn tính

IV. Khám bệnh


Tồn thân:
Tri giác: Tỉnh táo, tiếp xúc tốt.

Tổng trạng: trung bình ( BMI = 50 : 1,6 2 = 19,14 )
Da, niêm mạc bình thường.
Dấu sinh hiệu:



Mạch: 88 lần/phút



Huyết áp: 160/80 mmHg



Nhịp thở: 22 lần/phút



Nhiệt độ: 37oC



Các cơ quan:
Tuần hoàn: Nhịp tim đều, tiếng T1-T2 rõ không tạp âm bệnh lý.
Hô hấp: Lồng ngực cân đối, rì rào phế nang, hai phổi êm dịu, khơng
ral rit, ral ngáy.
Tiêu hóa: Bụng mềm, khơng chướng, khơng điểm đầu khu trú trên
thành bụng.
Các bộ phận khác: Sơ bộ bình thường.



Chẩn đoán vào viện: I10 - Bệnh lý tăng huyết áp



Bệnh kèm theo: E16 - Hạ glucose máu khác


Phụ lục 1



Các y lệnh thuốc và chăm sóc:
Captopril stella 25g 1viên (ngậm dưới lưỡi)
Efferalgan 500mg

1 viên (sủi)

Tổng phân tích tế bào máu ngoại vi
Xét nghiệm đường máu mao mạch
Điện tim tại giường


Phân cấp điều dưỡng: Chăm sóc cấp 2

PHẦN II: CẬN LÂM SÀNG


Phụ lục 1

Tên xét nghiệm

Kết quả

Trị số bình thường

Tổng phân tích tế bào

QTXN
XN-QTHH

máu ngoại vi bằng máy
đếm laser
WBC

10,98

4,50 - 9,0010^3/mm^3

NEU#

9,13

2,0 - 6,9 g/L

NEU%

83,1

37 -80%

LYM#

1,27

0,60 - 3,40

LYM%

11,5

21 -42%

MONO

0,48

0,0 -9,0%

MONO%

4,4

2,00 - 15,0%

EO#

0,08

0,0 - 0,70 dL

EO%

0,8

0,00 - 7,00 %

BA#

0,02

0,0 - 1,2 dL

BA%

0,2

0,00 - 1,200 %

RBC

4,61

3,7 - 5,2 M/uL

HGB

13,6

9,0 - 16,5 g/dL

HCT

41,4

35,0 - 45,0 %

MCV

89,8

80,0 - 92,0fL

MCH

29,5

26,0 - 33,0pg

MCHC

32,9

31,0 - 37,0 g/L

RDW

14,3

8,00 - 15,0 %

PLT

331

150 - 350K/uL

XN-QTHH

MPV

7,0

5,0 - 12,0fL

XN-QTHH

PCT

0.232

1-10%

XN-QTHH

PDW

13.0

7.0-20%

XN-QTHH

XN-QTHH


Phụ lục 1

CÁC CẬN LÂM SÀNG KHÁC
Tên xét nghiệm

Kết quả

Chỉ số bình thường

Xét nghiệm đường máu mao mạch

tại 6.6

3,9 - 6,4 (mmol/L)

tại giường (một lần)

Đo điện tim: Kết luận là nhịp xoang

SINH LÝ BỆNH VÀ SO SÁNH TRIỆU CHỨNG.
CƠ CHẾ BỆNH SINH: Suy tim được khởi đầu bằng một quá trình
bệnh lý làm tổn thương cơ tim, dẫn đến làm chức năng tế bào cơ
tim và cuối cùng ngăn cản sự hoạt động co bóp bình thường của

tim.
BẢNG SO SÁNH LÝ THUYẾT VÀ LÂM SÀNG

QTXN