护理查房的表格

护理查房的 查房内容名称_______________________________________________ ______________ 查房日期______________主讲人_____________________ 地点______ _______ _______ 参加人员___________________________________________________________________ ___________________________________________________________________________ 护理评估: 患者姓名 性别 ___ _ 年龄 __ 床号 住院号 民族 文化程度 宗教信仰 职业 婚姻 入院日期 入院方式 ?平车 ?轮椅 ?扶行 ?步行 入院诊断 既往史 药物过敏史 ?无 ?有 T ? P 次/分 R 次/分 BP / ?Hg 身高 ? 体重 ? 意 识 ?清楚 ?嗜睡 ?朦胧 ?躁动 ?昏睡 ?谵妄 ?浅昏迷 ?深昏迷 ?痴呆 精神,心理 ?平静 ?烦躁 ?焦虑 ?恐惧 ?抑郁 ?依赖 ?愤怒 ?否认 ?自卑 其他 皮肤情况 ?正常 ?潮红 ?苍白 ?黄疸 ?紫绀 ?皮疹 其他 ____ ?压疮 部位 分级 范围 ?外伤 部位 分级 范围 口腔黏膜 ?正常 ?异常 义齿 ?无 ?有 肢体活动 ?行动正常 ?使用助行器 ?残肢 ?无法行动 其他 饮 食(食欲)?正常 ?减低 ?增加 其他 (食物禁忌)?无 ?有:种类 睡 眠 ?正常 ?失眠 ?服镇静剂 其他 残疾 ?盲 ?哑 ?失聪 大 便 ?正常 ?失禁 ?腹泻 ?便秘 ?肠造口 其他 __ 小 便 ?正常 ?失禁 ?尿频 ?尿潴留 ?尿少 ?留置导尿管 其他 嗜 好 ?不吸烟 ?吸烟 ?已戒烟 ?不饮酒 ?偶饮酒 ?大量饮酒 ?已戒酒 疾病认知 ?明确 ?不明确 分值_________ 日常生活功能评估 护理风险评估 压疮风险 ?无 ?有 分值 __ 跌倒/坠床风险 ?无 ?有 分值 _ 导管脱落风险 ?无 ?有 分值 其他 主证及简要病情:___________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 治疗原则:_________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________护理诊断:_________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________护理目标:_________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________护理:_________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 健康教育要点:_____________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 相关知识提问:_____________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 小结:_____________________________________________________________________ ___________________________________________________________________________ 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