When writing bladder instillation nursing records, you can record them in the following format:
Date: The date on which the nursing operation is recorded.
Time: Record the specific time of nursing operations.
Patient information: including patient name, age, gender and other basic information.
Nurse/Nurse: Name of the nurse or caregiver performing the nursing action.
Nursing operations: Describe the specific steps of nursing operations, including specific methods of bladder instillation, drugs or solutions used, infusion time, etc.
Observation and evaluation: Record the conditions observed during the nursing process and the patient's reaction, such as the color and volume of urine, pain or discomfort, etc.
Notes: Record matters that require special attention, such as whether there are any adverse reactions, requirements to comply with medical advice, etc.
Nursing measures: Record the nursing measures implemented, such as taking care of the patient's comfort, keeping the urinary catheter unobstructed, etc.
Doctor's order evaluation: record the doctor's requirements or evaluation of nursing operations.
Signature: The nurse or caregiver signs at the end of the record to confirm that the nursing action was performed accurately.
It should be noted that records should be accurate, detailed, and objective, and avoid using vague or subjective descriptions. Record every detail of nursing operations in a timely manner to ensure complete and traceable information.