The results of measuring body temperature, pulse, respiration and blood pressure are recorded on the temperature list as required. Recording requirements: the data is correct, the handwriting is clear, all written in blue and black ink, the dots are the same size, and the connection is straight, so as to achieve the purpose of accuracy, beauty and neatness.
First, the recording method of each item on the temperature list.
1. Fill in the following items with blue pen in the eyebrow column: ① Name ② Admission date ③ Department (ward) ④ Bed number ⑤ Admission number (medical record number); ⑥ Date: Write down the month and day of the year on the first day of each warm list, such as September 30th, 1995. The middle month should be indicated, such as 30, 10- 1 2.
2. Between the horizontal lines of 42-40℃, record the following items in the corresponding date and time with a blue pen; ① Admission time; 2 operation (no name); ③ Delivery time; (4) change the subject (indicate the subject); ⑤ discharged from hospital; ⑥ Time of death; All landowners go out; 8 refuse to try.
Any time required to write should be written in Chinese for ×× hours× minutes.
3. Between the horizontal lines of 35-34℃, when the body temperature is
4. Record the following items by breathing, record the Arabic numerals with a blue pen, and do not record the unit of measurement.
(1) Breathing times. The number of adjacent breaths should be staggered up and down.
(2) The frequency of defecation. Fill in the stool frequency of the previous day every 24 hours, and if there is none, record 0; After enema, you should add a short slash to write "e", for example, 3/E means defecation three times after enema, and 3/2E means defecation three times after two enemas; 1/2/E means that it will be released once and twice after enema; Writing "*" in artificial anus indicates fecal incontinence.
(3) Record the statistical data of liquid intake and discharge the day before.
(4) The urine volume is the same as above.
(5) Use space to maneuver, and record figures such as sputum volume, extracted fluid and abdominal circumference. Remember the number of milliliters of liquid, the number of centimeters of length and the name of the unit.
(6) Fill in the weight in kilograms. Anyone who cannot be weighed for various reasons will be recorded as "bedridden".
(7) Blood pressure is expressed as a fraction. There are no extra units.
(8) Generally, the date after the operation is recorded within one week, such as "II- 1" on the first day of the second operation, "II-2" on the second day, and so on. This grid can also be used to record the days when patients with acute infectious diseases are sick or maternal delivery.
(9) The page number should be filled in with a blue pen.
Second, the temperature and pulse recording method
1. Body temperature is recorded according to the measured readings and cannot be converted. In the temperature list, each compartment is 0.2℃, and the five compartments are 65438 0℃.
(1) The oral temperature is "●" with blue spots.
(2) The underarm temperature is indicated by a blue cross.
(3) Rectal temperature is indicated by blue circle.
Points, forks and circles are connected by blue lines.
(4) The body temperature after physical cooling, such as warm water or alcohol rubbing bath and arterial ice compress, is indicated by red circle and connected with the body temperature before physical cooling by red dotted line. Primary body temperature should also be related to the body temperature before physical cooling.
(5) In case of refusing to try, going out or not rising, the two temperature curves before and after should be disconnected.
2. The pulse and temperature list is 4 times in each compartment and 20 times in 5 compartments.
The pulse rate of (1) is "●" with red dots and connected with red lines.
(2) The heart rate is connected by red circle "○" and red line.
(3) When the body temperature and pulse overlap, draw the body temperature first, and the red circle outside the body temperature indicates the pulse. For example, when the anus thermometer measures the body temperature, draw a red circle in the blue circle to indicate the pulse, such as X.
(4) If it is necessary to record the pulse deficit chart, fill it in with a blue pen between the heart rate and the pulse rate.
Extension: the daily aphorism of nurses
1. Nurses should respect themselves and not look down on themselves; Nurses should love themselves and not let others look down on them; Nurses should strengthen themselves, arm themselves with scientific knowledge and improve their comprehensive quality.
2. Caring, careful, compassionate, diligent in eyes, diligent in hands, diligent in legs and keen in observation. This is a high-quality team of nurses.
3. Love grows around us, and we grow in love.
The patient is not an unintelligent person, but a person who makes us intelligent.
5. Work is love that the eyes can see. Nurses will let all eyes see and all blind people feel the love contained and displayed in our work! Love flows in our work; Love spreads through our work.
6. Mammy, love everyone, including those who love you and those who despise you; Whether you like it or you hate it.
7. Nurses are all cash-strapped rich people! Our prosperity lies in our spirit. Our work is great and full of love. Because "love spreads through our work!" We are "caring workers who build a paradise on earth!"
8. Nurses should have a pair of willing hands and a kind heart.
9. Since you have chosen, you must pay without regrets; Maybe I don't ask for anything in return, but I have a clear conscience and deserve to be called an "angel".
10, no profession can combine the beauty of human mind and the goodness of behavior with the cleverness of hands and the softness of will like nursing, so that they can be fully displayed.
1 1, beauty is always just a mood. When you are in a good mood, everything is beautiful and peaceful!
12, I can become a nurse because of the call of God, because people are the most precious, and it is a sacred job to take care of people and make them recover.
13. Work hard, be frank and open.
14. Things are complicated, things are idle, things are faithful, things are rigid without desire, and harmony is precious if it is in the spring breeze, if it is in the autumn, it is money-oriented, and the outer circle is inside.
15, the sun is new every day and tomorrow will be better.
16, I don't work for hospital leaders, I work for patients, and I work to take care of patients.
17, believe in yourself, nurse, is an excellent team! As long as we persist and work hard, we will finally usher in a brilliant tomorrow!
18, treat the world with kindness, do everything with optimism, handle things with cheerful hands, and do everything with humor!
19, only to satisfy patients is the purpose of all our work. We must understand that I work for myself, not for my parents.