英文護理查房模板

匯報人：xxx20xx-03-18英文護理查房ppt模板目錄PatientInformationNursingCarePlanVitalSignsMonitoringMedicalAdministrationWoundCareandDressingChangesNutritionandDietaryNeedsDischargePlanningandFollowupArrangements01PatientInformationBasicInformationFullNameTobefilledinbythenumberormedicalstaffMale/FemaleGenderTobefilledinbythenumberormedicalstaff(Note:Ageshouldberepresentedasanumericalvaluewithoutanyreferencetospecificyears,decks,orcenters.)AgeBasicInformationBasicInformationNationalityOccupationAllergiesTobefilledinbythepatientortheirrepresentativeListofknownallergies,ifanyTobespecifiedbythepatientortheirrepresentativePreviousIllnessSummaryofsignificantpastmedicalconditionsSurgeriesDetailsofanyprevioussurgicalproceduresHospitalizationHistoryofhospitaladmissionsandreasonsforadmissionMedicationsCurrentandpasttreatments,includingdosagesandfrequenciesMedicalHistoryCurrentmedicaldiagnosisorreasonforadmissiontothewardDiagnosisRegularmonitoringofvitalsignssuchastemperature,pulse,respirations,andbloodpressureVitalSignsListofcurrentsymptomsexperiencedbythepatientSymptomsOngoingtreatments,therapies,andtreatmentsadministeredtothepatientTreatmentsCurrentConditionNursingNeedsAssessmentEliminationAssessmentofBowelandBladderfunction,includinganyassistancerequiredNutritionEvaluationofthepatient'snutritionalstatusanddietaryrequirementsMobilityAssessmentofthepatient'sabilitytomoveindependentlySkinIntegrityObservationanddocumentationofskincondition,includinganysoundsorlossesEmotionalWellbeingEvaluationofthepatient'semotionalstateandsupportneeds02NursingCarePlanGoalsofCare01Ensurepatientsafetyandfortduringhospitalization02Provideholographicnursingcarethataddressesthepatient'sphysical,emotional,andsocialneeds03Preventplicationsandpromoteoptimalhealthoutes04Facilitypatientandfamilyeducationforself-careanddischargeplanningAssesspatient'scondition,vitalsigns,andpaylevelregularlyImplementfallpreventionmeasuresandassistwithinflammationasneededAdministertreatmentssafelyandmonitorforsideeffectsProvideemotionalsupportandmunicationwiththepatientandtheirfamily01020304KeyNumberingInterventions01Patient'sphysicalandemotionalneedsaremet,andtheyreportfeelingfortableandcaredforComplicationsarepreventedormanagedeffectivelyPatientandfamilydemonstrateunderstandingofself-careinstructionsanddischargeplanningPatientremainssafeandfreefrompreventableaccidentsorinjuries020304ExpectedOutputsRegularassessmentofpatient'sconditionandvitalsignstoidentifyanychangesorconcernspromptFeedbackfromthepatientandtheirfamilyonthequalityofcarereceivedAchievementofexpectedoutputsandprogressrewardscaregoalsDocumentationofnursinginterventionsandpatientresponsestocareEvaluationCriteria03VitalSignsMonitoringBloodPressureandHeartRateRegularmonitoringofbloodpressureandheartrateisessentialforassessingthepatient'scardiovascularstatusRecordreadingspromptandinformthemedicalteamofanysignificantchangesUseappropriateequipmentandtechniquestoensureaccuratemeasurementsAdvisorfactorsthatmayaffectbloodpressureandheartrate,suchasanxiety,pain,andmedicineInspirationandOxygensaturation01Monitorthepatient'srespiratoryrate,depth,andefforttoidentifyanyrespiratorydistress02Measureoxygensaturationusingapulseoximetertoassesstheequalityofoxygendeliverytotheissues03Observeforsignsofrespiratorydistress,suchasincreasedworkofbreaking,useofaccessmolecules,andchangesinskincolor04AdjustoxygentherapyasneededtomaintainequaloxygensaturationlevelsTemperatureandPainAssessmentRegularlymonitorthepatient'stemperaturetodetectanyfeverorhyperthermiaAssessthepatientforpaintregularlyusingavalidatedpaintassessmenttoolUsearelatedmethodoftemperaturemeasurement,suchasatypicoraxialthermometerImplementappropriatepaymanagementstrategies,includingpharmaceuticalandnonpharmaceuticalinterventions01020304AbnormalFindingsReportingImmediatelyreportanyabnormalvitalsignsorconcernedfindingstothemedicalteamClearmunicatethenatureoftheanomalyandanyrelevantcontextualinformationDocumentallabnormalfindingspromptandaccuratelyinthepatient'smedicalrecordParticipateinfollowingupdiscussionsanddecisionmakingregardingthemanagementofabnormalfindings04MedicalAdministrationListofmedicinesReviewthepletelistofmedicinesthepatientistaking,includingthename,dose,route,andfrequencyVerifythecorrectdosageformsandstrengthsforeachmedicineEnsuremedicinesareadministeredatthecorrecttimesaccordingtothesubscribedscheduleCheckforpotentialdruginteractionsandcontraindicationswithothertreatmentsthepatientistakingDosageformsandstrengthsAdministrationtimesDruginteractionsMedicationScheduleReviewPatientweightandbodysurfaceareaCalculatethepatient'sweightandbodysurfaceareatodeterminetheappropriatedoseDosagecalculationPerformthenecessarycalculationstodeterminethecorrectdoseofeachmedicineVerificationprocessImplementarobustverificationprocesstoensurethecorrectdiagnosesanddosagesareadministeredDocumentationAccuratelydocumentallmedicaladministration,includingthedate,time,medicalname,dose,androuteDosageCalculationandVerificationFollowestablishedguidelinesfortheadministrationofeachmedicine,includingtheuseofappropriateequipmentandtechniquesAdministrationtechniquesAssessthepatient'sconditionandabilitytotolltheadministrationofmedicinePatientassessmentImplementstrictinfectioncontrolmeasuresduringmedicaladministrationtopreventcrosscontaminationInfectioncontrolProvideeducationtopatientsandtheirfamiliesontheimportanceofmedicaleducationandproperadministrationtechniquesPatienteducationAdministrationTechnologyGuidelinesCommonsideeffectsBeawareofthemonsideeffectsassociatedwitheachmedicineandmonitorthepatientfortheiroccurrenceAdvancedreactionsImmediatelyreportanyadversereactionsorunexpectedsideeffectstothehealthcareteamforfurtherevaluationandtreatmentPatientmunicationEnhancepatientstoreportanyunusualsymptomsorchangesinconditionthatmayberelatedtotheirdiagnosesDocumentationAccuratelydocumentallsideeffectsandadversereactions,includingthedate,time,symptoms,andanyactionstakenSideEffectsMonitoring05WoundCareandDressingChangesObservesoundforsignsofinfection,inflation,orcrossingVisualInspectionRecordwonsize,depth,andanychangesinappearanceorconditionMeasurementEvaluatepatient'spainlevelandanydiscomfortassociatedwiththewoundPainAssessmentKeepdetailedandaccuraterecordsofsoundassessmentsandtreatmentsDocumentationWoundAssessmentandDocumentationDressingSelectionandApplicationTechniqueDressingTypesPatientComfortSterileTechniqueDressingChangesChooseappropriatedressingbasedonroundtype,location,andexitlevelApplydressingusingSteriletechniquetopreventinfectionChangedressingregularlyaccordingtofacilityprotocolandsoundconditionsEnsuredressingareappliedinawaythatmaximizespatientfortHandHygienePerformhandhygienebeforeandafterallwoncareproceduresCleanWonBedCleanwonbedwithappropriatesolutiontoremovedebrisandbacteriaProtectiveBarriersUseprotectivebarrierssuchasglovesandgownswhennecessaryEnvironmentalControlsMaintainacleanandsafeenvironmentforroundcareInfectionPreventionMeasuresWoundClosure:MonitorwonforsignsofhealingsuchasgranulationissueformationandwoncontractEvaluateexitlevelandmanageappropriatelytopromotehealingPainReduction:Monitorpatient'spaylevelandadjusttreatmentplanifnecessaryFollowupCare:ArrangeforfollowupcareandmonitoringafterdischargefromthehospitalorclinicHealingProgressMonitoring06NutritionandDietaryNeedsNutritionalAssessmentRecommendationsConductaprehensivenutritionalassessmenttoidentifythepatient'sspecificneedsAdvisorfactorssuchasage,weight,height,gender,andanyunderlyinghealthconditionsRemendapersonalizednutritionalplanbasedontheassessmentfindingsMonitorthepatient'sprogressandadjusttheplanasnecessary01Developamedicalplanthatmeetsthepatient'snutritionalrequirementsandpreferences02Provideguidelinesonportsizes,foodgroups,andcalorieintake03Offersuggestionsforhealthycookingmethodsandimportantsubstitutions04EncouragethepatienttoparticipateinmealplanningandpreparationMealPlanningandPreparation