First, the home page
The homepage is mostly in tabular format, which mainly includes the general situation, brief medical history, psychological state, nursing physical examination, etc. (Table 23-2). In the record, we should pay attention to:
1. Reflect objectively without any subjective bias. Subjective information obtained from patients and their families should be enclosed in quotation marks.
2. Avoid uncertain words, such as "average", "slightly worse" and "average".
3. In addition to the * * * items that must be understood, further information should be collected according to personal conditions to judge and determine nursing problems.
Second, plan the nursing list.
Refers to the written records of nursing diagnosis, nursing objectives, nursing measures and nursing evaluation (Table 23-3).
1. Nursing diagnosis is an existing and potential health problem for patients.
2. Nursing goal is the guide of planning and the basis of evaluation.
3. Nursing measures are specific plans for nursing diagnosis.
4. Evaluation is a record of patients' feelings and objective examination results during and after nursing.
There is no completely unified standard for the writing of nursing plan, which is roughly as follows: ① Individualized nursing plan; ② Standardized nursing plan; ③ There are three kinds of nursing plans made by computer.
Third, the course of disease records
Nursing course record is a record of the patient's condition, recovery and progress, including the record of estimated data, the record of nursing measures, the record of the implementation of doctor's orders and the patient's response to medical treatment and nursing measures (Table 23-4).
Of course, the frequency of recording depends on the patient's condition. General patients record every 3-4 days 1 time, critically ill patients record every day, and special circumstances are recorded at any time.
Fourth, nursing summary
Nursing summary is a summary record of nurses' nursing for inpatients according to nursing procedures. Including the patient's admission status, the implementation of nursing measures, whether the nursing effect is satisfactory, whether the nursing objectives are achieved, whether the nursing problems are solved, whether there are nursing complications, nursing experiences and lessons and existing problems, etc.
Five, discharge guidance
Discharge guidance refers to the guidance and training given to patients before discharge. Discharge guidance is the continuation of hospitalization nursing plan, which helps patients to transition from hospital environment to family environment, enables patients to acquire self-care ability, consolidates curative effect and improves health level.
Guiding principle of discharge: according to the patient's disease characteristics, personality characteristics, education level, social status and economic conditions, it should be focused, easy to understand and individualized.
The content of discharge guidance: according to the patient's physical and mental condition and his understanding of the disease, put forward the matters needing attention in diet, medication, rest, functional exercise, health care and regular review after discharge.
The nurse in charge should record the health guidance to the patients after discharge in the nursing summary (discharge summary) and write another copy to the patients.
Table 23-2 Home Page of Nursing Medical Records
Name crown × sex, male age, bed number 72. 13 hospitalization number 179872
Senior high school education level of retired cadres of Han nationality is 94.9. 13.
1 1
The recording time of admission diagnosis and discharge diagnosis of bronchial asthma was 94.9. 13.3pm, and the military doctor was informed of the time.
√
Admission mode: lying position, sitting position and walking position.
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Hospital treatment: bathing, changing clothes, untreated.
Admission introduction: symptomatic education, hospitalization guidance (diet, rest, hygiene, visiting, accompanying guests, material storage, etc. )
Causes of admission: intermittent asthma for eleven years, aggravated for three months, and dyspnea for one day.
Nursing examination: √.
Consciousness: awake, lethargic and in a trance.
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Breathing: steady, difficult, sitting, breathing. Cough: phlegm, no phlegm.
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Expression: Normal, cold and painful face. Reaction to light: existence, dullness, disappearance.
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General nutrition is good, general, poor and cachexia. Limb movement: avoid paralysis.
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Normal skin, yellow dyeing, dehydration, boils, bedsore.
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The hearing of the five senses function ear is normal and decreased. The quality of nasal ventilation. Allergy history (presence or absence).
√ √
Oral mucosa is normal, with ulcers and white spots. Gum: normal, red and swollen, bleeding.
No drainage or wound.
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The mental state is joyful, anxious, sad, fearful and missing. Others:
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Disease knowledge
Understand the requirements of nursing and hope to get good care.
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Habits and diet: cereal sleep: good, insomnia. Hobbies: Nothing special.
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-
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Normal urination, constipation, incontinence.
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Admission nursing diagnosis
Inefficient breathing pattern, severe wheezing; Exercise has no endurance, and breathing is intense; Constipation, less activity in the elderly; Insomnia is related to daytime sleep.
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Signature of head nurse: Zhang × signature of responsible nurse: Zhao ×
Table 23-3 Planned Nursing
Name: Crown Hospital. 13 hospitalization number 179872
Date nursing diagnosis and effect evaluation of nursing target nursing measures
9- 13 inefficient breathing mode: due to severe breathing, it is characterized by wheezing.
Activity has no endurance, and due to breathing, it is manifested as fatigue and decreased activity level.
The patient's wheezing symptoms were relieved within 1 week, and he could keep breathing effectively.
1 week, the patient mastered the limitation of activity and duration, and was able to alternate activities and rest.
1. Closely observe the patient's condition change, and observe and record the patient's breathing mode, including breathing frequency, depth, rhythm, cyanosis, dyspnea, etc.
2. Inhale the patient with low flow (2 liters/minute) oxygen continuously through the nasal catheter.
3. Give antiasthmatic and antispasmodic drugs according to the doctor's advice, and observe and record the effects of drugs on breathing patterns.
4. During the patient's dyspnea, wait and comfort the patient and give emotional support.
5. Keep the indoor air fresh and ventilate for half an hour every morning and evening.
6. Instruct the patient to breathe slowly with contracted lips and abdomen.
7. Note that the infusion speed should not exceed 20 drops/minute.
8. Raise the patient's bedside, take a half-lying position to rest in bed, and assist the patient in life care.
1. Observe and record the patient's tolerance level to daily activities.
2. Instruct patients to master the limit of activities, and stop activities when sweating in case of wheezing and dyspnea.
3. Assist patients in life care.
4. Ask the patient to ask the nurse for help when there is something with a large amount of action or activity, and don't be overworked.
5. With the improvement of the condition, instruct the patients to gradually increase the activity and exercise the activity endurance (the activity range is gradually from the bedside room to the outdoor, and finally achieve self-care.
6. Provide patients with a diet with high protein, high calorie, high vitamins and cellulose, increase nutrition and enhance physical activity endurance.
9. The goal of18 was completely achieved-the patient's wheezing symptoms were relieved and his breathing was stable.
9.20 The goal has been completely achieved-patients can master the limits and duration of activities, and take activities and rest alternately, so that they can take care of themselves.
Table 23-3 Planned Nursing Sheet
Name: Crown Hospital. 13 hospitalization number 179872
Date nursing diagnosis and effect evaluation of nursing target nursing measures
9- 13 constipation: due to the old age and reduced activity, constipation of patients can be relieved within 3 days, and a large number of patients can remain unobstructed. Patients are required to drink more water at ordinary times, not less than 1500ml per day.
2. Increase the cellulose content in patients' diet, and ask family members to bring bananas, fruits and bees to patients during their visits.
3. During wheezing relief, assist patients to get out of bed.
4. Give oral laxatives when necessary.
5. Explain to patients the knowledge needed to maintain normal excretion pattern, including diet, proper activities, drinking water, etc.
9. 16 The goal was completely achieved-the patient's stool kept its shape.
9- 14 Insomnia: Patients related to daytime sleep returned to normal sleep within 2 days: 22:00pm~6:00pm, complaining of good sleep at night. 1. Establish a new life order and adjust the psychological rhythm with new life rules.
① After the condition is stable, ask the patient not to sleep from 7: 00 to 9: 00 in the morning. When he wants to sleep, he listens to the tape and reads the newspaper. ② Require family members to talk with patients during the day, so that the cerebral cortex can often get excited and stimulated through information exchange and enhance mental activity.
2. Eating some animal protein during the day (animal protein contains tyrosine, which has the effect of anti-5- hydroxytryptamine) excites the cerebral cortex.
Don't drink strong tea or watch intense TV and novels before going to bed.
4. Assist patients to do some activities to help them sleep before going to bed, don't eat too much at dinner, and wash their feet with warm water before going to bed.
9. The goal of16 was completely achieved-the patient was in good mental state and slept normally.
Table 23-4 Nursing Course Records
Name button: number of inner bed. : 13 hospitalization number: 179872
Date and time of nursing record
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9- 13
30
1 1
be
The patient was admitted to the hospital by his family, introduced the ward environment to the patient, and took the patient to the bedside. The patient was short of breath, so he raised his bedside, gave him continuous low-flow oxygen inhalation for 2 liters/minute, and told the doctor to introduce the visiting system, diet system, article management system, accompanying life system, hospitalization instructions, work and rest time, etc. To the patient and his family, hoping for cooperation. Because wheezing patients have poor appetite, it is necessary to help them eat and strengthen basic nursing. Treatment according to the doctor's advice to give anti-inflammatory and asthma symptomatic treatment. Zhao x
3pm had a simple conversation with patients, learned about their past living habits, diet, medical history and family situation, and made a nursing plan.
30
3? /P & gt；
afternoon
The patient suddenly gasped, wheezing, unable to lie flat, sweating, cyanosis, nausea and vomiting. Inform the doctor immediately, wait beside the patient, clean up the vomit and comfort the patient not to be too nervous. Stop intravenous drip of penicillin according to the doctor's advice, intravenous drip of hydrocortisone 200mg, intramuscular injection of asthma 0.25g, intravenous injection of dexamethasone 5mg, and Shuchuanling aerosol once. Symptoms eased after 2 hours. Zhao x
9- 14 9: 00 a.m. Nursing asked about the patient's condition. The patient complained that he didn't sleep well last night, only slept for 2-3 hours and couldn't lie flat. He received health education and intravenous injection. Zhao x
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30
nine
be
The patient suddenly suffered from asthma again, sweating cyanosis, sitting, dyspnea and wheezing. Inform the doctor immediately, stop penicillin intravenous drip, give hydrocortisone 200mg intravenous drip, asthma 0.5g intramuscular injection, flumethasone 5mg intravenous injection, and keep the ward quiet. After half an hour, the symptoms were relieved and asthma recurred, all of which were related to penicillin infusion. Suggest whether to stop penicillin treatment. Zhao x
3pm talks with patients to understand their coping ability, give comfort, and instruct them to breathe with contracted lips and abdomen, wash their faces and feet, trim their nails, and take care of their lives. Zhao x
9- 15 10am patients are in good mental state, sitting, complaining of good sleep at night, no wheezing and feeling good about themselves. Talk to the patient to understand the patient's psychological state. During the conversation, I learned that patients are not satisfied with their children and can't visit them often. Sometimes I feel very angry. Encourage patients' children to get married, have children to take care of, work hard and be considerate, give patients dietary guidance, guide patients to eat more crude fiber vegetables and fruits every day, and take appropriate activities to prevent constipation. Zhao x
9- 16 10am patients are in good mental state, complaining of relieved wheezing and no chest tightness recently. Zhao x
3pm assists patients in activities, gives simple self-care guidance, and enhances patients' confidence in overcoming diseases.
9- 18 2pm patients are generally in good condition, with no complaints of discomfort, good appetite, recumbent, stable breathing and coherent language. Recently, the patient complained of shaking hands, explaining to the patient that it was a side effect of Shuchuanling, which would gradually improve after stopping taking the medicine. Zhao x
After 9-20 nights of nursing at 3 pm, the patients have been able to take care of themselves, have a cheerful personality and are satisfied with the nursing work. He told the patient to change clothes according to the temperature change and pay attention to exercise on weekdays. Zhao x
9-23 2pm patient's condition is stable, and he will be discharged tomorrow, and the patient will be given discharge guidance. Zhao x
Nursing summary
Through the nursing of the patient, the nursing plan was formulated and implemented, and the patient could understand and actively cooperate, and achieved certain results.
Through nursing this patient, I think the lesson to be learned in nursing work is that it is very necessary to observe the side effects and curative effects of drug treatment for every patient. In addition, it is very important to do a good job in psychological care of patients and eliminate their psychological unfavorable factors.
Discharge guidance
Take the medicine on time according to the doctor's advice after discharge and review it regularly.
Live regularly on weekdays, pay attention to climate change and avoid catching a cold.
Properly strengthen nutrition, enhance physical fitness and improve physical resistance.
Pay attention to rest and avoid fatigue.
Keep a good mood and eliminate fear.