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How to describe the shortness of breath relief nursing document?

1. According to the requirements of the two "Notices", the nursing documents that nurses need to fill out and write include: body temperature sheets, medical orders, surgical inventory records, and care records for seriously ill (critically ill) patients. Nursing documents can be in table format. 2. Nursing documents are an integral part of medical records. The written content should be organically combined with other medical records and unified with each other to avoid duplication and contradiction. Writing nursing documents should be objective, truthful, accurate, timely and standardized. (1) Body temperature sheet. The temperature sheet is mainly used to record the patient's vital signs and related conditions, including the patient's name, age, gender, department, bed number, admission date, hospitalization record number (or medical record number), date, length of hospitalization, number of days after surgery, Pulse, body temperature, respiration, blood pressure, intake and output, stool frequency, weight, height, page number, etc. (2) Long-term medical orders. The content of the long-term medical order includes the patient's name, department, bed number, hospitalization record number (or medical record number), start date and time, content of the long-term medical order, stop date and time, physician's signature, nurse's signature, and page number. Among them, the doctor fills in the start date and time, the content of long-term medical orders, and the stop date and time. The medication orders, infusion orders, treatment orders, etc. that nurses carry out long-term medical orders every day are signed by the executing nurse and are not included in the medical record. (3) Temporary medical order. The content of the temporary medical order includes the patient's name, department, bed number, hospitalization record number (or medical record number), date and time, content of the temporary medical order, physician's signature, execution nurse's signature, execution time, and page number. Among them, the doctor fills in the time of the medical order and the content of the temporary medical order; the nurse who executes the temporary medical order fills in the execution time and signs. (4) Operation inventory records. The contents of the surgical inventory record include the patient's department, name, gender, age, hospitalization record number (or medical record number), operation date, operation name, blood transfusion status, inventory and verification of the various instruments and auxiliary materials used during the operation, surgical instrument nurses and Signature of circulating nurse, etc. The surgical inventory record should be completed immediately after the surgery and signed by the surgical instrument nurse and circulating nurse. (5) Nursing records of seriously ill (critically ill) patients. Nursing records for seriously ill (critically ill) patients apply to all seriously ill, critically ill patients, as well as patients whose condition changes and require monitoring. Nursing records are recorded in the form of a nursing record sheet, which includes the patient's department, name, age, gender, bed number, hospitalization record number (or case number), admission date, diagnosis, recording date and time. Observation is required according to the characteristics of the specialty. Monitored items, treatment and nursing measures taken, nurse signature, page number, etc. Nursing records should be designed and written according to the nursing characteristics of the corresponding specialty, with the principles of simplicity and practicality.