护理记录范文（Nursing records）.docVIP

护理记录范文（Nursing records） Transfer to nursing records The contents of the nursing records were transferred to the first care Transfer to nursing records example 1 11.1 13:15 In twelve by the emergency department into the car, into the ward, diagnosis of open fracture (fracture) in the right hand right ankle infusion, 500ml 60gtt/min more than 200 Ringers group, ML, right ankle pain and bleeding caused by three hours of private car accident, view was conscious, poor spirit, painful appearance, pale tongue, thin white fur, pulse fine, check the temperature of 36.8 pulse 98 beats / min 23 min after admission blood pressure breathing 96/56mmHg active preoperative preparations, to patients and their families. The preoperative and postoperative precautions, and given preoperative anesthetic drug application, at twelve thirty into the operation room, Department of education has been done into the comfort, dont be nervous, patients and their families expressed understanding. Transfer to nursing records example 2 1.11 14:00 Patients in 14:00 from four families into a stretcher into the ward, the four families into the indwelling gastric tube and trocar indwelling catheter, patients, trance, facial edema, double conjunctival edema, blood 11.1mmol/L, T37.7 P92 R20 Bp140/80mmhg C / min / min Four, turn out nursing records The content includes the general condition of the patient out of the (vital signs, consciousness, activity, skin, positive signs), the patient complained of symptoms (nausea, headache, head fan), patients are nursing treatment (ECG, pulse oximetry, oxygen inhalation, hibernation therapy), will be transferred to the Department. Turn out the nursing record example 1 9.20 14:10 T36 C, P86 / min, R20 / min, Bp120/80mmHg. Fluency in speech, muscular strength of the limbs, and overall skin. ECG showed: heart rate 86 beats / min, arrhythmia, atrial fibrillation. Private prosecution: palpitation, chest distress. Long instructed infusion is over, oxygen inhalation at 3L/