Admission time:
Chief complaint: diarrhea and vomiting for 3 days, oliguria 1 day.
Treatment: (What medicine)
Then write down what tests you have done, such as blood routine, stool routine, vomit and so on.
Then put forward nursing problems, countermeasures and nursing effects.
For example:
1. dehydration-related to frequent defecation.
A. Use antidiarrheal drugs and antibiotics according to the doctor's advice.
B the patient's skin elasticity is weakened, the anterior fontanel and eye socket are obviously sunken, and the oral mucosa is dry. Fluid replacement can be given according to the doctor's advice.
Nursing effect: it is the change of patients after you use the above measures.
2. acidosis-1day, less urine, frequent vomiting, cherry red lips.
A. Apply drugs to improve acidosis according to the doctor's advice. Fasting and rehydration can be done when necessary.
B patients with dry oral mucosa should have oral care twice a day.
3. Risk of red buttocks-related to defecation 10 times or more every day.
A. change diapers in time. Wash with warm water after each defecation and apply tannic acid ointment.
B. If red buttocks have already appeared, you can apply cod liver oil I degree; When the second mixing is damaged, apply zinc oxide cod liver oil to dry the wound and bake it with a baking lamp of 40 to 60 watts 15 to 20 minutes, 20 cm away from the buttocks. When using the baking lamp, apply cod liver oil locally to avoid baking injury, keep warm and prevent pneumonia.
Then there are potential nursing problems, such as psychological nursing and health education. Write these down.
If you just write a nursing record sheet, write T P R, then your nursing physical examination results and the nursing measures you have taken.