The fourth quarter special nursing record sheet

A, special nursing record sheet writing requirements

1. Fill in the blank items in the eyebrow column with a blue pen.

2. The patient's temperature, pulse, breathing, blood pressure, intake, medication, illness, changes in treatment effect, nursing process, etc. should be recorded in a timely, accurate and complete manner, and there should be a clear summary and signature when the shift is changed.

3. The records from 7: 00 a.m. to 7: 00 p.m. are written in blue, and the records from 7: 00 p.m. to 7: 00 a.m. are written in red. Names of all vital signs and liquid-free units.

4. The total amount of liquid in and out should be summarized at 7 o'clock in the evening, and summarized with a red pen at 7 o'clock the next morning; According to the needs of the disease, make a classification summary first, and then summarize.

5. In chronological order, record the implementation of standby doctor's advice in the corresponding column.

6. When the patient dies, write a death summary.

Second, the special nursing record demonstration

Special care record

Name: Room 6, Bed 5, Kebaina Ward, Li Wei Hospital 155867 Time, temperature, pulse, respiration, blood pressure, food and liquid discharge, illness and treatment.

Name the quantity by month and day

6-16 7: 38 37.5108 3618.6/9.35% sodium bicarbonate 250

The patient was admitted to the hospital at 7: 15 for acute infectious polyradiculoneuritis. Because the lesion involved the upper thoracic nerve root, breathing was shallow and fast (36/min), tracheotomy was performed and simple artificial respirator was used.

5% glucose saline 500

Vitamin C 10

9 o'clock milk 200

10: 00 37.4108 3017.3/9.3 There are many secretions in the trachea, so it is necessary to suck sputum and steam 15 minutes.

12: 00 1 10 28 17.3/65438+

14: 00 37.41202814.610.6 20% mannitol 250 vomited 80 times, and it was light yellow mucus.

15:30 lotus root powder soup 200 sputum 30 sputum suction, steam inhalation

16: 00 37.6963216/10.4 urine 300 disinfected the internal intubation and dropped a few drops of gentamicin into the trachea.

The patient underwent tracheotomy, simple artificial respiration machine, assisted breathing, shallow breathing, more tracheal secretions and critical condition. He suffered from hypoxic brain damage and has been reported to the doctor on duty for treatment. Please continue to closely observe the patient's breathing and other vital signs.

Day shift: Min Xu.

6-1617: 001023016/10% glucose solution 500

Vitamin B6 4

Vitamin C 20

Dexamethasone 2

10% potassium chloride 10

19:00 Urine 200

6- 16 12 hours summary inhalation 1948 discharge 640

19:10381203213.1/8.5 sputum 100.

The patient's blood pressure has a downward trend. 60 ml of gastric juice was extracted by inserting a gastric tube, and the color was brown. The specimen has been sent for inspection. The doctor on duty thinks that the patient may have bloody gastritis.

Gastric juice 60

Stop using dexamethasone, switch to interferon, disinfect tracheal tube and drop gentamicin.

6- 16 20:00 1 14 28 128/ 9.3

21:001163012/9.210% glucose solution 500 urine 200 urine samples were given intravenous drip.

Cimetidine 0.4g 4

At 22:00 120 28 12/8 iced saline 100 gastric juice 100, the gastric juice was brown.

Norepinephrine 8 mg 8

23:00 37.5 120 30 12.5/6.7

24:00 96 26 12/7.2 200 patients with blood transfusion were in a shallow coma, with large eyes, slow response to light and unstable blood pressure. Considering that due to upper gastrointestinal bleeding, brown gastric juice 160ml was taken out at night, and occult blood test was+++,and breathing was still maintained by ventilator, and the patient was often attracted, and the liquid was continuously dripped, which was critical.

Ye yuan on night shift

6-171:00120 30 9.3/6.7 physiological saline 100 gastric juice 80

When 80ml of brown gastric juice is pumped out, it suddenly twitches, the pupils dilate, the response to light disappears, the heart sounds are unclear, and tidal breathing occurs.

Dopamine 20 mg 2

M-hydroxylamine 20 mg 2

1:30 5.3/0 10% glucose solution 250 gastric juice 20

1:40001.0/01%epinephrine 1mg 1.

Breathing and heartbeat stopped, pupils dilated by 8mm, and chest compressions were performed after three intravenous injections. After being rescued, he died at 2: 05.

Night shift Zhang Lin

Promethazine 1 mg 2

Atropine 1 mg 1

Three intravenous injections

* Night and night shift records should be recorded in bold in red ink.