Using nursing procedures to care for patients requires systematic, complete records that reflect the entire nursing process, including patient information, nursing diagnosis, nursing goals, nursing plans and effect evaluation, which constitute nursing medical records. The writing requires detailed records, highlighting key points, clear priorities, logic, clear text and correct use of medical terminology.
1. Home page
The home page is mostly in table format, and the main content is the patient’s general situation, brief medical history, mental state, and nursing physical examination (Table 23-2). Attention should be paid to the following in the record:
1. Reflect objectively without any subjective bias. Subjective data obtained from patients and their families should be enclosed in quotation marks.
2． Avoid words that are difficult to determine, such as "fair", "slightly worse", "fairly good", etc.
3. In addition to the comprehensive items that must be understood, further information should be collected based on individual circumstances to determine nursing issues.
2. Planned nursing order
Refers to the written record of nursing diagnosis, nursing goals, nursing measures, and nursing evaluation (Table 23-3).
1. Nursing diagnoses are existing and potential health problems of patients.
2． Goals of care serve as guidelines for planning and as a basis for evaluation.
3. Nursing measures are specific plans developed for nursing diagnosis.
4． Evaluation is the record of patient feelings and objective examination results during and after nursing care.
There is no completely unified standard for writing nursing plans. There are roughly three categories: ① individualized nursing plans; ② standardized nursing plans; ③ computer-developed nursing plans.
3. Disease course record
Nursing course record is a record of the patient’s condition dynamics, recovery and progress, including records of estimated data, nursing measures, records of implementation of medical orders, and Patient response to medical and nursing measures (Table 23-4).
The frequency of disease course recording depends on the patient's condition. Generally, patients are recorded once every 3-4 days, critically ill patients are recorded every day, and special cases are recorded at any time.
4. Nursing summary
Nursing summary is a summary record of the nursing care provided by the nurse according to the nursing procedures during the patient's hospitalization. Including the patient's status when admitted, the implementation of nursing measures, whether the nursing effect is satisfactory, whether the nursing goals are achieved, whether the nursing problems are solved, whether there are nursing complications, nursing experience lessons and existing problems, etc.
5. Discharge guidance
Discharge guidance refers to the guidance and training given to patients on the eve of discharge. Discharge guidance is the continuation of the inpatient care plan, which helps patients transition from the hospital environment to the home environment, allowing patients to gain self-care abilities, consolidate curative effects, and improve their health.
The principle of discharge guidance: according to the patient's disease characteristics, personality characteristics, education level, social status, and economic conditions, it should be focused, easy to understand, and given according to individual needs to meet individual requirements.
Content of discharge guidance: Based on the patient's current physical and mental status and understanding of the disease, it provides precautions in terms of diet, medication, rest, functional exercise, health care, and regular review after discharge.
The responsible nurse should record the patient's health instructions after discharge after the nursing summary (discharge summary), and write another copy to give to the patient.
Table 23-2 Home Page of Nursing Medical Records
Name × Gender Male Age 72 Bed No. 13 Hospital No. 179872
Ethnic Han, retired professional cadre, education, high school marriage Married Admission time 94.9.13
11
Admission diagnosis of bronchial asthma Discharge diagnosis record time 94.9.13.3pm Notification time to military doctor
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Admission mode: lying, sitting, walking
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Admission treatment: bathing, changing, and no treatment.
Admission introduction: Symptomatic education, hospitalization instructions (eating, rest, hygiene, visiting, accompanying guests, material storage, etc.
Reason for admission: Intermittent asthma for eleven years, worsening for three months , had difficulty breathing for one day
Nursing examination: √
Consciousness: clear, drowsy, trance
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Respiration: steady, Difficulty, orthopnea. Cough: phlegm, no phlegm.
Expression: normal, indifferent, painful face. Reaction to light: present, dull, disappeared. p>
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The whole body is well nourished, normal, poor, and cachectic. Limbs can move freely
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The skin is normal and yellow. Infection, dehydration, boils, and bedsores.
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The facial features and hearing are normal or decreased. Nasal ventilation is good or not.
√ √
Oral mucosa is normal, with ulcers and white spots. Gums: normal, red, swollen, and bleeding.
No drainage and wounds.
√
Mental state: cheerful, anxious, sad, fearful, missing. Others:
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Understanding of the disease
General understanding of nursing requirements and hope for good care
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Lifestyle Diet: Cereals Sleep: Good, insomnia Hobbies: None. Special
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Normal defecation, constipation, and incontinence
p>
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Admission nursing diagnosis
Inefficient respiratory pattern, severe wheezing; activity Insufficiency of endurance, severe wheezing; constipation, less activity in old age; insomnia, related to daytime sleep.
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Signature of head nurse: Zhang× Signature of the responsible nurse: Zhao Evaluation of the effectiveness of measures
9-13 Inefficient breathing pattern: caused by severe wheezing, characterized by suffocation.
Activity intolerance, caused by wheezing, manifested as fatigue and decreased activity level.
The patient's wheezing symptoms were relieved within 1 week and he was able to maintain effective breathing.
The patient masters the limits on the amount and duration of activity within 1 week and is able to alternate activities and rest.
1． Closely observe changes in the patient's condition and record the patient's respiratory pattern, including respiratory frequency, depth, rhythm, presence of cyanosis and dyspnea.
2. Give the patient continuous low-flow (2 liters/min) oxygen through the nasal cannula
3. Follow the doctor's advice to give antiasthmatic and antispasmodic drugs, and observe and record the effect of the drugs on respiratory patterns.
4. During the patient's period of difficulty breathing, stay with the patient, comfort him, and provide emotional support.
5. Keep indoor air fresh and ventilate for half an hour in the morning and evening every day.
6. Instruct the patient to perform slow, pursed-lip abdominal breathing.
7. Pay attention to the infusion speed not exceeding 20 drops/minute
8. Allow the patient to elevate the head of the bed and rest in a semi-recumbent position to assist in daily care.
1． Observe and record the patient's level of tolerance for daily activities.
2. Instruct patients to master the limits of their activities and stop activities once they experience wheezing, difficulty breathing, or sweating.
3． Assist patients with daily care.
4. Instruct the patient to ask the nurse for help when he has to move or do something with a large amount of activity, and not to overwork himself.
5. As the condition improves, guide the patient to gradually increase the amount of activity and exercise endurance (the range of activities gradually changes from indoor to outdoor at the bedside, and finally to self-care.
6. Provide patients with high-protein, high-calorie, and high-vitamin nutrition and a multi-fiber diet to increase nutrition and enhance physical activity endurance.
The 9.18 goal is fully achieved - the patient's asthma symptoms are relieved and the breathing is stable.
The 9.20 goal is fully achieved. ——The patient can control the amount and duration of activity, alternate activities and rest, and can take care of himself.
Table 23-3 Planned Care Sheet
Name, Section, and Category. Inner bed number 13 Hospital number 179872
Date Nursing Diagnosis Nursing Objectives Nursing Measures Effect Evaluation
9-13 Constipation: Due to aging and reduced activity, the patient’s constipation was relieved within 3 days and To maintain a large amount of fluid, ask the patient to drink more water, at least 1500ml per day
2. Add fiber content to the patient's diet, and ask family members to bring bananas, fruits and honey to the patient when visiting.
3. Assist the patient to get out of bed and move appropriately when necessary.
5. Knowledge required for physical condition, including diet, appropriate activities, water intake, etc.
The goal of 9.16 is fully achieved - the patient's stool maintains its shape.
9-14 Insomnia: Daily. Patients related to intermittent sleep returned to normal sleep patterns within 2 days: 22:00pm~6:00pm, and complained of good sleep at night. 1. Establish a new life order and adjust the psychological rhythm.
① When the condition is stable, instruct the patient not to sleep from 7:00am to 9:00am. When he wants to sleep, he can listen to the recording and read the newspaper. ② Instruct the family members to talk to the patient more during the day. Through information exchange, the cerebral cortex can often be stimulated. Enhance mental activity.
2. Eat some animal protein during the day (animal protein contains tyrosine, which has an anti-serotonin effect) to stimulate the cerebral cortex.
3. Do not drink strong tea or watch intense TV or novels before going to bed.
4. Help the patient do some activities to help him sleep, do not eat too much at dinner, and wash his feet with warm water before going to bed. >
The goal of 9.16 was fully achieved - the patient was in good spirits and slept normally.
Table 23-4 Nursing Course Record
Name Kou Department: Bed Number: 13 Hospitalization Number 179872
Date and Time Nursing Record
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9-13
30
11
am
The patient is admitted to the hospital with the help of his family members. The patient is introduced to the ward environment and brought to the bedside. If the patient wheezes heavily, raise the head of the bed and give continuous low-flow oxygen inhalation of 2 liters/min. The doctor will be notified and the patient and family members will be informed of the visitation system, diet system, item management system, companionship system, hospitalization instructions, and work and rest time. Waiting for introduction, hoping to get cooperation. As wheezing patients have poor appetite, they must be assisted in eating and basic care must be strengthened. In terms of treatment, anti-inflammatory and anti-asthmatic treatment will be given according to the doctor’s instructions. Zhao×
3pm Have a simple conversation with the patient, understand the patient’s past living habits, dietary status, medical history and family situation, etc., and formulate a care plan Zhao×
30
3?/Pgt;
pm
The patient suddenly wheezed with asthma sounds, could not lie down, sweated profusely, was cyanotic, and had nausea and vomiting. Notify the doctor immediately, stay by the patient's side, clean up the vomitus, and comfort the patient not to be too nervous. According to the doctor's advice, the intravenous infusion of penicillin was stopped, and intravenous infusion of hydrocortisone 200 mg was given, intramuscular injection of 0.25 g of Chuanding, intravenous injection of 5 mg of flumetasone, and one spray of albuterol aerosol. Symptoms relieved after 2 hours. Zhao ×
9-14 9am The morning nurse inquired about the patient's condition. The patient complained that he had poor sleep last night, only slept for 2-3 hours, and could not lie down. The patient was given health education and intravenous infusion. Zhao ×
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30
9
am
The patient suddenly developed asthma again, with profuse sweating, cyanosis, sitting upright, dyspnea and wheezing. Immediately notify the doctor, stop the intravenous infusion of penicillin, give intravenous infusion of 200 mg of hydrocortisone, intramuscular injection of 0.5 g of Chuanding, and intravenous injection of 5 mg of flumetasone, and keep the ward quiet. After half an hour, the symptoms were relieved, and the asthma recurred, both with Regarding the input of penicillin, it is recommended whether to stop penicillin treatment. Zhao ×
3pm Talk to the patient, understand the patient's coping ability, provide comfort, and guide the patient to perform lip-tuck abdominal breathing, wash the patient's face, feet, trim nails, and provide daily care. Zhao ×
9-15 10am The patient is in good spirits and sitting upright. He complains that he sleeps well at night, has no wheezing, and feels good about himself. Talk to the patient to understand the patient's mental state. During the conversation, we learned that the patient is not very satisfied with his children, cannot visit them often, and sometimes feels very angry. He comforted the patient that his children were married and had children to take care of. He had a heavy workload and needed to be more considerate. He also provided dietary guidance for the patient, instructing him to eat more vegetables and fruits with crude fiber every day and take appropriate activities to prevent constipation. Zhao ×
9-16 10am The patient is in good spirits and complains that his wheezing has been relieved in recent days and he has no symptoms of chest tightness. Zhao×
3pm Assist the patient with activities, provide simple self-care guidance, and enhance the patient’s confidence in overcoming the disease. Zhao×
9-18 2pm The patient is generally in good condition, with no complaints of discomfort and appetite. OK, you can lie down, breathe steadily, and speak coherently. The patient complained that he had hand tremors recently. He explained to the patient that it was a side effect of albuterol and that it would gradually improve after stopping the medication.
Zhao ×
9-20 3pm Evening care, the patient can take care of himself, is in a cheerful mood, and expresses satisfaction with the nursing work. He tells the patient to add or remove clothes according to changes in temperature, and to pay attention to physical exercise on weekdays. Zhao ×
9-23 2pm The patient’s condition is stable and he will be discharged from the hospital tomorrow. The patient will be given discharge guidance. Zhao ×
Nursing Summary
Through the care of this patient, a nursing plan was formulated and implemented in detail. The patient was able to understand and actively cooperate, and certain results were achieved.
Through caring for this patient, I think the lessons that should be learned in nursing work are: it is very necessary to observe the side effects and efficacy of drug treatment for every patient. In addition, it is very important to provide patients with psychological care and eliminate their psychological disadvantages.
Discharge Instructions
After discharge from the hospital, follow the doctor’s instructions to take medicine on time and review regularly.
Practice your daily life, pay attention to climate changes, and avoid catching colds.
Appropriately strengthen nutrition, enhance physical fitness, and improve the body's resistance.
Pay attention to rest and avoid fatigue.
Keep your mood comfortable and eliminate fear.