急性阑尾炎护理记录(国外英文资料).docVIP

急性阑尾炎护理记录 Medical school of teaching and education Graduation intern (specialist) Study number: name: the examination room: Nursing record Department number ___________ ___________ ___________ ward bed in hospital, _____ First nursing record The time () Patient, man (female),... The main reason for... , in... Month... Day... When to... Income. On April 20, 2015, the patient Lin feng, male, 8 years old, the main cause of the persistent umbilical cycle pain was 3 hours in 2009 on April 20, 2015 in the acute appendicitis. A brief history of history: 3 hours ago, children have no obvious cause feeling periumbilical pain, dull pain, the persistent, brave cold, fever, abdominal distension, vomiting, and anal, stop exhaust and defecate, no dysuria. In outpatient diagnosis and treatment, the abdominal pain is not lessened, also no apparent aggravation, the hospital to be admitted, the disease come to the spirit, the diet poor, two normal, the weight no change. Brief history, personal history and psychosocial situation: The history of non-genetic and infectious diseases, the history of non-infectious diseases, and the health of parents. ? Lifestyle and self-care: life can be self-sustaining. Psychosocial evaluation: the patient is affected by the parents mood, the psychological strain, the prognosis of the disease is very much. Body evaluation: Body evaluation: T: 38.8 ℃? P: 101 times/min?? R: 22? Times/min?? , BP20.3/13.3 kPa? (100/60mmhg), normal development, medium nutrition, divinity, step into the ward, automatic position, body and cooperation. Normal development, medium nutrition, pale skin, mucous membrane, no hemorrhagic points, yellow dye. There is no swelling in the superficial lymphocyte. The head and the five senses are not deformed, the ear, the nose is not abnormal secretion, the neck is soft, the trachea is centered. The thoracic flatness, the two lungs breath sound smooth, the heart does not enlarge, not smell and other pathological noise. The abdomen is sof