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1、精选优质文档-倾情为你奉上护理病历首次护理记录单姓名：陈观连 性别：男 年龄: 71岁 科室: 心内科一区 床号：HNL01 住院号/ID号：入院日期时间：2016-11-5 14:37 职业：其他 民族/宗教：汉族/无 婚姻状态：已婚教育程度：中学 资料来源：患者 日常照顾者：自我照顾入院方式：步行 入院类型：门诊 过敏史：有（磺胺类）医疗费用支持方式：其他社会保险 入院诊断：冠心病既往史：冠心病、PCI术、高血压病、肾功能不全、慢性胃炎、痛风、下肢动脉粥样硬化、下肢深静脉瓣膜技能不全、颈动脉硬化一、护理评估 意识状态：呼之能应; 对答：切题；饮食：自行进食 咀嚼困难：无 吞咽困难：无 口腔
2、黏膜：完整 胃肠道症状：无 睡眠：正常 醒后疲劳感：无排尿：未发现异常 排便：正常（1次/天）；四肢活动：自如自理能力：完全自理 皮肤状况：完整 语言沟通：最常用语言/语种：粤语 ，语言表达：清楚生活习惯：吸烟：无 嗜酒：无伤口：无 敷料：无 造瘘：无 患者自我护理：能 静脉置管：无 留置引流管：无疼痛：无患者在最近1周内是否有膳食摄入减少：否；压疮风险：无；跌倒/坠床风险：有；走失风险：无最近3个月是否有体重减轻：否其他症状和体征：无二、住院告知住院须知 物品管理 作息 探陪 订餐 介绍主管医生 介绍护士长 介绍主管护士 三、护理重点1. 基础护理：更衣护理、饮食护理2. 专科护理：3. 患
3、者安全：身份识别、转运安全、上床栏、防跌倒四、其他五、护理交接班重点：注意患者血压情况 记录时间：2016年11月 05日14 时56 分 责任护士签名：石彩兰审核时间：2016年 11月05日16 时52 分 审核人签名：黄清华护理记录单姓名：姓名：陈观连 性别：男 年龄: 71岁 科室: 心内科一区 床号：HNL01 住院号：入院日期：2016-11-5 日期时间体温脉搏次/分呼吸次/分血压mmHg血氧饱和度吸氧/L入量 ml尿量ml大便次数共/次特殊情况记录护士签名2016-11-514:5336.76820143/739621已行入院宣教，患者无诉不适石彩兰11-617:0037.07
4、219142/72972共350共6000床边BNP结果：18.14pg/ml，PCT结果为:0.1ng/ml，CTNT结果为：50ng/ml,已通知医生石彩兰11-79:1736.96718159/91982予硝酸甘油0.5mg舌下含服，异舒吉50mg以5ml/h静注石彩兰11-79:3037.27119142/89972共400共7001恶心呕吐一次，胃内容物量约80ml，予胃复安肌注。石彩兰11-810:2237.37517144/7998212016-11-08 肌钙蛋白定量：高敏肌钙蛋白定量0.554ug/ml，结果已报告医生，患者现无诉不适，指导患者静卧休息，床边二便，避免用力排便
5、。石彩兰11-816:0036.86920140/83992共350共9001患者准备明天行CAG术，已做好术前准备。遵医嘱予NS 250ml慢滴。石彩兰11-99:1036.77421135/76982共200共8000在家属及医生的陪同下送患者至心导管室行CAG术。石彩兰11:0037.17216139/86100停共500共7501患者行PCI术后安返病房，术后情况详见术后护理介入记录单，遵医嘱予心电监护，示窦性心律。石彩兰11-1010:0037.06919135/8299共450共8000患者无诉不适，遵医嘱予停心电监护。石彩兰11-118:3036.57820145/9698共42
6、0共9501患者今早8am口服药全部掉落地面，遵医嘱予波立维75mg、拜阿司匹林100mg、螺内酯片20mg、丽倍乐20mg、倍他洛克95mg、万爽力20mg口服。石彩兰11-1414:0036.67918148/8199共350共10001患者诉仍间有胸闷不适，予异舒吉喷雾一只交患者备用，已指导使用方法。石彩兰11-1512:0036.77517133/7299共450共8501患者出院，指导患者低盐低脂饮食，定时监测血压，按时服药，勿情绪激动，勿用力排便，不适随诊。石彩兰病人出院指导一、 休息和功能锻炼1根据年龄及病情选择低强度的有氧运动，如步行、慢跑、打太极拳等。要采取循序渐进的方式来增
7、加活动量，一般每周35次，每次3060分钟。2外出运动时请随身携带硝酸甘油，如出现胸闷、胸痛时应立即停止运动就地休息并含服硝酸甘油，如症状10分钟无缓解请立即至医院就诊或呼叫120。 二、生活、工作中注意事项 1保持乐观情绪，避免紧张焦虑和情绪激动，多参加益于健康的娱乐活动，每天做些您感兴趣的事，保持身心轻松、愉快。避免过度劳累和用脑过度，生活有规律，保证充足睡眠。天气变化时，注意保暖，避免受凉。 2不宜用过热、过冷的水洗澡或蒸汽浴，洗澡时间不宜过长，门不应反锁。 3合并高血压，糖尿病，需严格控制好血压血糖，并注意监测血压及血糖。 4就诊其他疾病时应主动告知医生自己所患疾病、所行手术及服药情况
8、。三、饮食1控制能量的摄入，每日三餐最好定时定量，避免暴饮暴食。肥胖者应减轻体重，将体重指数（BMI）控制在25以下。（BMI=体重Kg身高m2，正常范围18.5-24） 2限制脂肪的摄入，特别是肥肉、动物内脏、蛋黄。烹调时，尽量选用植物油。限制盐的摄入量，每日应控制在6克以下（普通啤酒盖去掉胶垫后，一平盖食盐约为6克）。适量摄入优质蛋白质，如淡水鱼类。 3多食新鲜的蔬菜、水果及纤维素类食物以预防便秘，少量多餐，避免暴饮暴食。便秘时，不可过度用力，以免增加心肌耗氧，甚至诱发心肌梗死。 4戒烟，吸烟是引起冠心病的一个重要因素，吸烟者需立即戒烟。限酒，有饮酒习惯者，每周4-5天，可适当饮用红酒30
9、毫升/日。不饮咖啡、浓茶。四、自我监测和护理（药物治疗/伤口护理/病情观察等）：1遵医嘱用药，每天坚持并按时、按量服药，不能擅自停药、改药，自我监测用药的不良反应，药物的增减与更换应咨询专科医生。PCI术后氯吡格雷片应至少服用1年，阿司匹林肠溶片、他汀类、受体阻滞剂及ACEI（或ARB）等药物应终身服用。 2.指导继续使用抗凝、抗血小板、降脂药、硝酸酯类、钙通道拮抗剂、ACE-I类药物，详细说明用药剂量，时间，方法及药物的毒副作用。服用抗凝，抗血小板药物（如阿司匹林，氯吡格雷）时，应注意观察是否有血尿、黑便、难以止住的牙龈及鼻腔出血；服用他汀类药物时，应注意观察是否有肌痛、恶心等症状，一旦有上
10、述情况，请及时就诊，指导病人观察出血倾向。3日常生活中，特别是外出时，要携带冠心病急救药物（硝酸甘油），以备急用。可在运动、涉及情绪激动情况前，先把硝酸甘油含于舌下，以预防心绞痛发作。另外，硝酸甘油见光易分解，故应放在棕色瓶中，最好6个月更换一次。病情监测：教会患者心绞痛发作时的缓解方法，胸痛发作时应该立即停止活动，或者舌下含服硝酸甘油，连续使用三次若是没有缓解及时就医，应定期检查心电图，血压，血糖，血脂和肝功能等。4不要听信任何可根治冠心病的广告或宣传，避免上当受骗。五、复查1、服药过程中应1-2周至门诊随诊。每月应行肝肾功、血糖、血脂、血常规、凝血功能、心肌酶及心电图等检查。于介入治疗术后
11、6个月复查冠状动脉造影。2、 本科专家出诊时间： 我科室周一至周六设有主任门诊及普通门诊。 六、其他清淡饮食 低盐低脂 控制体重 适度运动 忌烟限酒 注意保暖 避免受凉 控制情绪 心态平和 愉悦生活 睡眠充足 遵嘱服药 定期复查 不适随诊七、护理小结（住院期间护理程序实施情况与存在问题）患者既往病史有很多，如慢性肾功能不全、下肢深静脉瓣膜不全、颈动脉硬化和痛风等，在患者住院期间中不仅要注重患者现存护理问题，也要注意患者潜在的护理问题，对患者的护理和宣教要做到认真和详细对待。Nursing recordsNursing record list for the first timeName: Ch
12、en Guanlian Gender: male Age: 71 years old Department:No.1 department of cardiology Bed number: HNL01 Hospital/ID number : Date of admission： 14:37, Nov 5th ,2016 Occupation：otherRace / Religions: Han /no marital status: Married Profession: other Education degree: Secondary school Date resource : Pa
13、tient daily caregivers: Self -care Admission form : Walk Admission type: Outpatient Clinic Allergy: SulfonamidesPay support: Other social insurance Hospital diagnosis: coronary heart diseasePast medical history: Coronary heart disease, PCI, Hypertension, Renal insufficiency, Chronic gastritis, Gout,
14、 Carotid artery artherosclerosis, Deep venous valvula insufficiency of lower extremities, Carotid atherosclerosis Nursing assessmentState of consciousness: call can be answer Answers: relevant;Diet: eating by himself Chewing difficulties: no Dysphagia: noOral mucosa: complete Gastro-intestinal sympt
15、oms: no Sleep: normal Tired after wake up: noUrination: normal Defecation: normal (1 time/day);Limbs activity: freely Self-care ability: fully Skin condition: completeLanguage communication: the most common language: Cantonese Language expression: clearHabits: no smoking, no drinking Wounds: noFistu
16、lization oral: no Vein tube: no Indwelling drainage tube: no Pain: noIntake reduced in latest week: no; Lose weight in the last 3 months: noRisk of pressure ulcers: no; Risk of fall/drop bed: yes; Risk of lost: noOther signs and symptoms: noAdmission GuideMaterial management、timetable、visit and acco
17、mpany rules、rules of order foods 、introduce charge doctor、charge nurse 、head nursenursing emphasis 1. basic nursing：clothes、diets2. Specialized nursing：3. Security：identification、safe transport、bedside rails、prevent a fall Otheremphasis of nursing hand-over process：blood pressureRecord time: 14:56,
18、Nov 5th，2016 Nurse signature: Shi Cailan Audit time: 16:52, Nov 5th，2016 Reviewer signature: Huang Qinghua Nursing record listName: Chen Guanlian Sex: male Age: a 71 years old Department:No.1 department of cardiology Bed number: HNL01 Hospital number: Date of admission： 14:37, Nov 5th ,2016 DateTime
19、TPTime/minRTim e/minBPmmHgSPO2%oxygen uptake(v/min)Intake VolumeOutputvolume Motions(time/minOthersSign2016-11-5 14:5336.76820143/739621To inform the hospitalizing education and patients without feeling unwellShi Cailan11-6 17:0037.07219142/72972All 350All 6000Had inform the results to doctor BNP re
20、sults: 18.14 pg/ml, PCT results as follows: 0.1 ng/ml, CTNT results: 50 ng/ml,Shi Cailan11-7 9:1736.96718159/91982To the sublingual nitroglycerin 0.5mg administering, intravenous isoket with 50 mg to 5 ml/h.Shi Cailan11-7 9:3037.27119142/89972All 400All 7001Patient feel nausea and vomiting once, and
21、 gastric contents is about 80 ml, and give metoclopramide intramuscular injection.Shi Cailan11-8 10:2237.37517144/799821Have been reported the result of quantitative troponin to doctor on Nov.8: quantitative high-sensitivity troponin is 0.554 ug/ml. Patient feel no discomfort, and guide patients to
22、rest, and bedside the bed ,and avoid defecating fiercely.Shi Cailan11-8 16:0036.86920140/83992All 350共All 9001Patients is ready to the CAG tomorrow. and follow the doctors advice to NS 250 ml in a slow drip.Shi Cailan11-9 9:1036.77421135/76982All 200All 8000Send patients to cardiac catheterization r
23、oom to CAG with doctors and families.Shi Cailan11:0037.17216139/86100停All 500All 7501Patients back to ward safely after PCI, and postoperative conditions can be found in the record of interventional nursing care after surgery ,and give ECG monitoring with the doctors advice. and show in sinus rhythm
24、.Shi Cailan11-1010:0037.06919135/8299All 450All 8000Patients with no discomfort, stop to ECG monitoring with the doctors advice.Shi Cailan11-118:3036.57820145/9698All 420All 9501The patients oral medications all fell on the ground at 8 am this morning. Then, give oral medications to patient with Pla
25、vix with 75 mg, Aspirin with 100 mg, Spironolactone with 20 mg, Spironolactone tablets with 20 mg, Betaloc with 95 mg, Rabeprazole Sodium Enteric-coated Capsules with 20mg ,and vasorel with 20 mg.Shi Cailan11-1414:0036.67918148/8199All 350All 10001patient still have chest discomfort, and give isoket
26、 spray to patients when needed, and has been guiding the method of usage.Shi Cailan11-1512:0036.77517133/7299All 450All 8501To give the patients discharge guidance with a low salt, low fat diet, regular monitoring of blood pressure, and take medicine on time, Do not emotional, not defecate forcibly,
27、 and review when feel discomfort.Shi CailanThe patient discharge guidanceRest and functional exercise1. According the patients age and condition to choose the low-intensity aerobics，such as walking, jogging, tai chi, etc. The patient should exercise 3 5 times a week generally, and every time is 30 t
28、o 60 minutes during the increasing activity step-by-step.2. Please carry nitroglycerin when you go out to exercise. If feel chest tightness, chest pain, you should stop exercising and taking nitroglycerin immediately on the rest. Besides, please go to the hospital or call 120 immediately if the symp
29、toms cant relief in 10 minutes.Attention in life and work 1. Try to keep optimistic mood, and avoid anxious and excited. It is beneficial to you to participate in more healthy entertainment activities. Try to keep relaxed and happy in physical and mental at every day, and do something what you are i
30、nterested in. Avoid overwork and overstrain nerves. Besides, try to assure enough sleep and keep a regular life. Be sure to keep warm and avoid catch a cold when the weather changes. 2. It is inappropriate to use overheating and overcooling water to bath or sauna. Showers time should not be too long
31、, and the showers door should not be locked. 3. The patient with hypertension and diabetes who need to control the blood sugar, blood pressure strictly and pay attention to the monitor blood pressure and blood sugar. 4. You should inform the doctor about the situation of disease, surgery and medicat
32、ion when you go to hospital to see other diseases. Self-psychological adjustment, adjust state of mind, alleviate psychological pressure, avoid excessive overworked, emotional, forcibly defecate. Diet1. Try to control the intake of energy: avoid overeating and three meals at regular diets per day. O
33、bese should reduce weight, and body mass index (BMI) under control 25. (BMI = weight Kg present height m2, normal range 18.5 - to 24)2. Limit the intake of fat meat, especially fat, liver, egg yolk .It is better to use vegetable oil during cooking. Besides, try to limit the intake of salt, and it sh
34、ould be controlled below 6 grams daily (after removing the common beers cover rubber gasket, a flat cover salt is about 6 g) .It is better to intake high-quality protein in proper quantity, such as freshwater fish, etc.3. You should eat enough fresh vegetables, fruit, and fiber foods in order to pre
35、vent constipation. Avoid overeating and eating more frequently in smaller meals. You shouldnt use excessive force when you have constipation, in order to avoid increase myocardial oxygen consumption, even induce myocardial infarction. 4. To quit smoking, because smoking is a major cause of coronary
36、heart disease. Smoker should be kicked the habit of smoke immediately. Drinkers should limit the intake of alcohol, but drinker can drink 30 ml/day with red wine 4 to 5 days a week appropriately. Dont drink coffee, tea, too.Self-monitor and care You should follow the doctors advice to take medicatio
37、n on time every day, and cannot change or stop without doctors agreement. Also, You should self-monitor the adverse reactions of drug, and increasing or decreasing and changing the drug should consult a specialist. The clopidogrel should be taken at least 1 year after PCI, and aspirin enteric-coated
38、 metformin hydrochloride, statins, beta blockers and ACEI or ARB drugs should be taken for the whole life.2.Guiding the drugs dosage ,time ,method and the side effects of drugs to the patient with nticoagulation and antiplatelet, lipid-lowering, nitrates, calcium channel blockers, ACE - I drugs. Tak
39、ing anticoagulants and antiplatelet drugs (such as aspirin and clopidogrel), should pay attention to observe whether there is blood in the urine, and black in defecation, and if there a difficulty to stop bleeding in the nasal and gums. The patient should observe whether there is a muscle pain, naus
40、ea when taking statins. Once the above situation appear , please do not hesitate to see a doctor, and instruct client to observe the bleeding tendency.3. You should carry the emergency drugs (nitroglycerin) of coronary heart disease especially go out in daily life in case of urgent need. But in orde
41、r to prevent heart attacks, you should sublingual nitroglycerin if involve emotional situation in motion at first. In addition, nitroglycerin is easy decomposes in the light, so it should be placed in brown bottle, and it is better to replace every 6 months. Teach the methods to relieve angina pecto
42、ris attack, and should stop the activity or sublingual nitroglycerin immediately when chest pain occur and seeing a doctor if use three times without relieving soon enough. The patient should check electrocardiogram blood pressure, blood sugar, blood lipid and liver function regularly, etc.4. Avoid
43、being deceived, and dont listen to any advertisement or publicity can cure coronary heart disease.Review1. The patient should have follow-up in out-patient clinic in 1 to 2 weeks in the process of the drug, and check the liver and kidney function, blood sugar, blood fat, blood routine, coagulation f
44、unction, myocardial enzymes and electrocardiogram examination at every month. The patient should review coronary angiography after percutaneous coronary intervention in 6 months.2, Expert visits and time information: there is director of the outpatient and ordinary outpatient service from Monday to
45、SaturdayOtherLight diet, low salt ,low fat, weight control ,moderate exercise, avoid smoke, wine limited, keep warm ,avoid catch cold, control mood ,calm, cheerful life, get plenty of sleep, follow the doctors advice to take medication Review of discomfort, follow-up on a regular basisNursing summary Patient has a many past medical history, such as chronic renal insufficiency, lower extremity deep vein valve insufficiency, gout