The homepage is in multi-table format, which mainly includes the general situation, brief medical history, mental state, nursing examination and other contents of the patient (Table 23-2). Records that should be noted:
1。 Reflect the objective, there is no subjective prejudice. In the use, the subjective data obtained from patients and their families are cited.
2。 Avoid uncertain words, such as "not bad", "missing a few points" and "not bad".
3。 The judge must know something about the same project, and should further collect information according to the individual's specific situation to determine the nursing problems.
Planned nursing sheet
Written records of nursing diagnosis, nursing objectives, nursing measures and nursing evaluation (23-3).
1。 Nursing diagnosis of patients and potential health problems.
2。 The purpose of nursing is to evaluate the guidelines and development basis of the plan.
3。 Nursing measures, made specific plans, nursing diagnosis.
4。 Evaluation of records and nursing, patients' feelings and the results of objective examination during 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) Three categories of computers, making nursing plans.
Notes of Sanjin
Nursing course records are records of patients' condition, dynamic recovery and disease progress, including estimated data records, nursing measures, records of executing medical orders and records of patients' medical nursing measures (Table 23-4).
The frequency of stadium recording depends on the patient's condition. The general patient's medical record lasts for 3-4 days, and the critically ill patients are recorded every day, and special circumstances are reserved.
IV nursing summary
Nursing summary during hospitalization and summary records of patients under nursing plan. Status and nursing measures, including whether the implementation effect of patients' hospital care is satisfactory, the realization of nursing objectives, the solution of nursing problems, the nursing of complications, nursing experiences and lessons and existing problems.
Discharged patients can receive guidance and training on the eve of discharge. Discharge guidance is a continuous hospital nursing plan, which helps patients to visit from the aspects of excessive hospital environment, family environment and patients' self-care ability, consolidate the curative effect and improve their health status.
Guiding principle of discharge: according to the patient's disease characteristics, personality characteristics, education level, social status and economic conditions, it is decentralized, easy to understand and individualized.
Discharge guidance: the patient's physical and mental condition and the level of understanding of the disease, and matters needing attention in diet, drug treatment, rest, functional training, medical care and regular review after discharge.
The responsible nurse should take good care of the patients after discharge (discharge summary), and the other part is the record summary of the patient health coach.
13 Hospitalization Table 23-2 Health Care Home
Name Crown × Sex Male Age 72 179 No.872
The wedding admission time for retired cadres and schools with high vocational education level 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 was informed.
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& gt admission mode: lying position, sitting position and walking.
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Tickets: shower, dressing, unprocessed.
Admissions brochure: symptomatic missionaries are hospitalized (diet, rest, hygiene, visiting rights, accompanying guests, and keeping materials).
Causes of hospitalization: intermittent asthma 1 1 year, increased to three months, one day breathing difficulties. BR/>； Health check: √.
Clear-headed, lethargic, unconscious
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Breathing smoothly, difficulty, sitting breathing and coughing: more phlegm without phlegm.
√BR/>； Expression: normal, cold, painful face. Photoreaction: Yes, dull and disappear.
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Generally, the nutrition is good, but the cachexia is poor. Limb movement: relieve paralysis.
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Normal skin, jaundice, dehydration, boils, bedsore
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There are good and bad facial functions of ear and nasal ventilation. People with allergic history (with or without). normality
√√
Oral mucosa, ulcer, leukoplakia The gums are normal, swollen and bleeding.
Leakage and wound
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The psychological state of happiness, anxiety, sadness, fear and desire. ：
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Understand the requirements of nursing and hope to get good care.
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Habit, diet: cereal sleep: insomnia hobby: special
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Normal urination, constipation and incontinence.
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Admission nursing diagnosis
Invalid breathing mode, severe wheezing, activity intolerance, severe wheezing, constipation, no old activity for many years, insomnia, daytime sleepiness.
& gt
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Signature of head nurse: Zhang×, signature of responsible nurse: Zhao×.
Table 23-3 Planned Nursing
In Mingguan, the telephone number of the hospital is 179 872.
Evaluation of nursing intervention measures on date nursing diagnosis and nursing objectives
9- 13 inefficient breathing mode: 13, caused by severe wheezing.
Activity intolerance, wheezing and weakness caused by activity level/> Patients with wheezing symptoms maintain effective breathing 1 week.
The activity level and duration of patients are limited to 1 week, which can replace activity and rest.
(1) Closely observe the changes of patients' condition and observe their breathing patterns, including breathing depth, rhythm, cyanosis, dyspnea, etc.
2。 Give the patient a continuous low-flow (2 liters/minute) nasal catheter oxygen inhalation.
3。 Kaiping antiasthmatic and antispasmodic drugs were used to observe and record the breathing patterns of specific drugs.
Wait and comfort patients with dyspnea and give emotional support.
5。 Keep the indoor air fresh for an hour and a half, and ventilate it every morning and evening.
6。 Instruct patients to slowly contract their lips and breathe abdominal.
7 Pay attention to the infusion speed not exceeding 20 drops/
Raise the patient's bedside, take a semi-lying position and rest in bed to help the patient take care of his life.
1。 Observe and record the patient's tolerance and daily activities.
2。 Instruct patients to master the limitations of activities, such as wheezing, dyspnea, sweating and stopping activities.
3。 Assist patients in life care.
4。 Ask the nurse a lot about the patient's actions or activities, and don't be overworked.
5。 Instruct patients to gradually increase their activity and exercise endurance activities with the improvement of their condition (the range of activities is gradually from bed to outdoor, and finally achieve self-care.
6。 Provide patients with a diet with high protein, high calories, high vitamins and high fiber, increase nutrition and enhance physical activity endurance.
9. The goal of18 was completely achieved-the patient's wheezing symptoms and breathing were stable.
Fully reached 9.20-patients can master the limitation and duration of activities, alternate activities and rest, and have been able to take care of themselves.
Table 23-3 Planned Nursing Sheet
The number of inpatient beds in Mingguan is 13 179 872.
Latest nursing diagnosis, nursing objectives, nursing measures and evaluation
9- 13 constipation: older, less activity. Patients should keep water every day, 1500 ml is a lot, because constipation can be relieved within 3 days.
& gt2。 Increase the cellulose content in the patient's diet and tell his family to visit the patient's bananas, fruits and honey.
3。 In order to relieve the patient's breathing opportunity and help the patient get out of bed and exercise properly.
Give oral laxatives when necessary.
5。 Explain the knowledge that patients need to maintain normal excretion patterns, including diet and appropriate activities, as well as water intake.
9. 16 goal-the patient's feces keep shape.
9- 14 insomnia: normal sleep mode is restored, and patients who sleep during the day will sleep for 2 days: 22:00 at night? At six o'clock in the afternoon, I slept well and complained 1. Establish a new life order, new life rules and psychological adjustment rhythm.
① After the condition is stable, instruct the patient to sleep at 7: 00-9: 00 am12: 00 am and listen to newspaper records. (2) talk show during the day, and told his family and patients to keep excited mood at all times, improve psychological activity, and make the cerebral cortex through information exchange.
2. Eating some animal protein during the day (animal protein contains anti-tyrosine and 5- hydroxytryptamine) will enhance the excitability of the cerebral cortex.
3。 Go to bed, don't drink strong tea or watch intense TV plots and novels. ....../a & gt；
4。 Help patients do some bedtime activities before going to bed to help them sleep. Don't eat too much for dinner, warm water and feet.
9. 16 fully realized goal-mental normal sleep of patients br/>;
Table 23-4 Notice of Nursing Progress
Oral sex: bed number: 13 hospitalization number: 179872.
Date and time of nursing record
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30,9- 13
I
It is hoped that doctors, patients and their families will be properly informed about the introduction of visiting system, catering system, material management system, escort live broadcast system, hospitalization time and rest time. Patients with wheezing have poor appetite, so it is necessary to help them eat. On the basis of strengthening basic nursing treatment, doctors should give advice on anti-inflammatory and anti-asthma symptomatic treatment. Zhao x
Talk with the patient at 3 pm to learn about the patient's past living habits, diet, medical history and family situation, and make a nursing plan.
30
3/P & gt；
afternoon
The patient suddenly developed asthma, wheezing, inability to lie flat, sweating, cyanosis, nausea and vomiting. Inform your doctor immediately, and wait for patients everywhere, clean up vomit and comfort patients who are not too excited. Stop intravenous drip of penicillin according to the doctor's advice, intravenous injection of hydrocortisone 200 mg, intravenous injection of flumethasone 5mg, spraying salbutamol aerosol once a day for 2 hours each time. Zhao x
9- 14 Nursing asked the patient about her condition from 9: 00 to 9: 00 in the morning. The patient complained that she didn't sleep well at night, only slept for 2-3 hours and couldn't lie flat. Health education for intravenous infusion. Zhao x
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30
nine
I
Suddenly, the asthmatic patient perspires, cyanosis, sits up, and has difficulty breathing with wheezing. Notify the doctor immediately. After symptoms and asthma stopped for half an hour, penicillin was given, hydrocortisone 200mg was given intravenously, dexamethasone 5mg was given intramuscularly, and the ward was kept quiet. Suggest whether penicillin treatment should be stopped. Zhao x
At 3 o'clock in the afternoon, talk about the patient, his ability, coping and comfort, guide the patient to breathe with his lips, abdomen, face and feet, and do a good job in life care. Zhao x
9- 15 in the morning 10, the patient was full of energy, sitting and complaining that he couldn't sleep at night, didn't have a chance to breathe, and felt good about himself. Talk about patients, understand their psychological state, and talk about whether patients are satisfied with their children. You don't have to visit them often, and sometimes you feel very angry. Comfortable children become patients who go home. Children need to be taken care of, with heavy workload and much consideration. Instruct patients to eat more crude fiber vegetables and fruits every day and take appropriate activities to prevent constipation. Zhao x
At three o'clock in the afternoon, assist patients in activities and give simple self-care guidance to enhance patients' confidence and overcome diseases.
At 2 pm on 9- 18, the patient was in good condition, with no chief complaint, good appetite, supine, stable breathing and coherent language. The patient complained about the recent tremor and explained the side effects of salbutamol to the patient. Withdrawal will gradually improve Zhao X.
During the evening nursing at 3: 00pm from 9th to 20th, the patients were able to take care of themselves and expressed satisfaction with the nursing work. He told the patient to change clothes according to the change of temperature and pay attention to exercise on weekdays.
At 2 pm on September 23, the patient was discharged from the hospital in a stable condition. Tomorrow, the patient will be discharged from the hospital for guidance. Zhao x
Nursing summary
Through the nursing of patients, a plan was made and implemented in detail. Patients can understand and actively cooperate, and achieved certain results.
Taking care of patients, I should learn a lesson: it is very necessary to observe the curative effect of drugs for each patient, and it is very important to do a good job in psychological care of patients and eliminate psychological factors that are unfavorable to patients.
Discharge guidance: after the routine drugs are discharged from the hospital, check the doctor regularly.
Live regularly, 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 excessive fatigue.
Keep a good mood and dispel their fears.