护理查房的表格

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

日常生活功能评估分值_________

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：_________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________护理措施：_________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 健康教育要点：_____________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 相关知识提问：_____________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 小结：_____________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________