臨 錄 料 臨 錄 3. 復

Transcription

1 Clinical Care Guideline of N.S.D Name 歷 Anamnesis NO. 修 訂 版 年 Date of birth 年 Blood Type Drug allergy 欄 NOTE

2 臨 錄 料 臨 錄 3. 復

3 料 Admission date 年 歷 Anamnesis NO. Name 年 Date of birth 年 Address for receiving info. Telephone number 連 Emergency contact 連 Telephone number 聯 Address for receiving info. Discharge date Bed NO. Sex ID NO. Cell phone number Relationship Cell phone number 年 Weight 數 Week Drug allergy kg Height EDC cm 年 Blood type Diagnosis Previous history

4 歷 / 臨 錄 Clinical Care Guideline Record of N.S.D. Pre-delivery Admission Physical assessment 料 年 2 (Wt) Kg (Ht) cm Basic physical data (TPR) BP mmhg 識 Consciousness (alert) (drowsiness) (stupor) (obtunded) 亂 (confusion) (irritable) (others) (pulse regular) 不 (arrhythmia) 律 (Pacemaker) (others) Cardiovascular (chest pain) Respiratory Gastrointestinal tract (respiratory tract)(smooth) (cough) (sputum) ( 量 ) (respiratory tract)(others) 率 律 (rate and rhythm of breathing)(normal) (rapid)(slow) (deep) (not deep) 率 (rate and style) (dyspnea) (others) (breath sounds )(normal) (wheeze) (stridor) (rhonchi) (breath sounds ) 裂 cracklessound (others) (bowel sounds)(normal)5-34 /min (rapid) (slow) (non) (abdomen)(bloating) (Soft) (hard) (tenderness) (Rebound tenderness) (mass)(others) 流 (drain)(n-g tube)( 量 _) (others) ( 量 ) Elimination 尿 (emiction)(normal) 尿 (micturition) 尿 dysuria (incontinence) 尿 (emiction) 尿 (on foley) (others) 便 (bowel pattern)(normal) 便 (constipation) (diarrhea) (incontinence) 便 (bowel pattern) (colostomy )( 數 狀 ) (others) Skin (condition) (color) (warm) 冷 (cold) (dry) (sweating) (pale) (flush)(cyanosis) (jaundice) (pink) (intact) (edema) ( 數 ) (lesion) (appearance) (trauma) (others) 力 Activity (normal) (weak) (bed rest) (handicapped)( ) (food) (drug) Allergic history (others) (smoking) 年 (cessation) Addiction (drinking) 年 (abstinence) (betel nut) 年 (quit) (drugs) (denture) ( ) (contact lens) (hearing aid)

5 歷 supplementary devices 臨 錄 Clinical Care Guideline Record of N.S.D. Pre-delivery (artificial eye) (artificial limbs) 行 (walkers) (others) 3

6 歷 臨 錄 Clinical Care Guideline Record of N.S.D. Pre-delivery 5 / (Pregnancy Physical assessment) Pregnancy history G P 流 (SA) 流 (AA) (ectopic pregnancy) 數 (week) (EDC) past history(pih) 糖 尿 (GDM) (Pre-eclampsia) past history(eclampsia) (show) at am/pm Signs of delivery (Hemorrhage) 量 (total amount) ml at am/pm Rupture of membranes at am/pm 狀 (clear) (turbid) Labor pain began at am/pminterval min 度 Duration sec Induced labor (reason) (method) at am/pm start at am/pm(dilation) cm Painless labor (Drug) Fetal position 露 (Presentation)(Vertex) (Face) (Brow) (Breech) Fetal head (Floating) (Partially engaged) (Engaged) 狀 Fetus (F.H.R.) / 量 (Estimated Weight) gm Examination bimanual palpation (monitor) (echography) (others) (VDRL) (Neg) (Pos) (AIDS) (Neg) (Pos) Blood tests 尿 Urine test Physiological Psychological Communication Others HBs Ag (Neg) (Pos) HBe Ag (Neg) (Pos) (rubella) (Neg) (Pos) CBCD/C(WBC) ul (Hgb) g/dl. (platelet) / ABOblood group/rh type( / Rh ) ( / Rh ) 異 (normal) 異 (abnormal) 尿 糖 (glycosuria) ( ) 尿 (proteinuria) ( )others (pain) others (anxiety) others (communication difficulty ) others L

7 歷 臨 錄 Clinical Care Guideline Record of N.S.D. Pre-delivery 錄 說 A. 了 B. 了 C. 不 了 A B C 力 惡 露 (special problem) 療 (medical / nursing intervention)

8 歷 / date/time F.H.R.(/) 臨 錄 Uterus contraction () Clinical Care Guideline Record of N.S.D. Pre-delivery TPR Dilation(cm) Effacement% Station (//) BPmmHg 療 Drug / intervention 4 Signature 年 年 年 年 年 年 錄 年 年 年 年 年 年 錄

9 歷 Rupture of Membranes 臨 錄 at am/pm (artificial) Clinical Care Guideline Record of N.S.D. Delivery 年 6 (spontaneous) Prenatal preparedness 尿 (on foley) at am/pm Fetal position 露 (Vertex).ROA (Presentation) (Face) (Vacuum Extraction) ml (skin prepare).loa.rop.lop.lot (Brow) (Breech) (Manual Rotation) Anesthesia (Local infiltration) (Saddle block) (Painless labor) 量 (total amount) severe moderate profuse / Amniotic fluid 便 (meconium stain)no 度 light 度 average 度 abundant Cervix Vagina Perineum Placenta intact 裂 lacerateddescription abrasion 裂 lacerated intact abrasion 切 (Episiotomy.) Midline RML LML. 裂 laceration at am/pm( spontaneous) (fundal pressure) 離 (Mechanism)(Schultz mechanism) (Duncan mechanism) (appearance)(complete).. 不 (incomplete) 裂 lacerated (appearance description) 量 (Weight)gm 量 (total bleeding) ml 留 ( gauze) Postpartum (uterus contraction)(hard) (soft) (delivery)at am/pm (sex) ( male) 女 (female) (stillbirth) (living) (suction) 狀 Postnatal data 異 (appearance) 便 (meconium stain) no 度 light 度 average 度 abundant 狀 (Umbilical cord) 狀 (Non) (Cord traction) (Loops) (Weight) gm (Height) cm (Head Circ) cm(chest Circ) cm skin to skinbeginat am/pm endat am/pm suck on the table

10 歷 臨 錄 Clinical Care Guideline Record of N.S.D. Delivery 7 (Score) 率 100 / 100 / (Pulse) (absent) (slow and below 100) (over 100) 不 力 Apgar Score (Respiratory Effort) 力 (Activity) (absent) 力 (Flaccid) (Hypoventilation and weak crying) 度 (Some Flexion of Extremities) (Good and strong crying) (Active Motion) (Grimace) (No response) (Lowering or some motion) (Cough or sneeze) 藍 藍 (Appearance) (Blue and Pale) ( Blue Extremities and pink body) (Completely Pink) (total) (Oxytocin) Piton-s 量 / a t am/pm Ergotrate 量 / a t am/pm 2% Xylocaine Local anesthesia 量 / a t am/pm Methergin 量 / a t am/pm (Plasma Expanders) B.T.() a t am/pmtotal _ml (Normal Saline) B.T.() a t am/pmtotal ml (special problem) 療 (medical / nursing intervention) 錄 錄

11 歷 臨 錄 Clinical Care Guideline Record of N.S.D.-- 1 st. Day Postpartum 年 9 / 復 (uterus contraction)(hard) (soft) Uterus recovery (Fundus) 惡 露 量 (amout) 量 (<1 ) 量 (<4 ) 量 (<6 ) 量 () Lochia (color) Perineal wound 尿 狀 Emiction 尿 不 尿 at a.m./p.m. 量 ml Hemorrhoid 不 狀 Activity Baby feeding Breast assessment (feeding method)(breast feeding) (mixed feeding) (formula feeding) 狀 度 (engorgement)(soft) (engorged) (partial engorged)(hurt) 泌 (lactation) 泌 (non) 泌 (a little) 泌 (a few) 泌 (plenty) (stretchiness) 良 (well) 不 良 (not well) (intact)(intact) 红 (sore nipple) 裂 (cracked)(dryness or crust) 暈 (vertigo) (pain) (others) (anxiety) (others) 說 A. 了 B. 了 C. 不 了 A B C 復 說 (special problem) 療 (medical / nursing intervention) 錄 錄

12 歷 臨 錄 Clinical Care Guideline Record of N.S.D. 2 nd. Day Postpartum 年 10 / 復 (uterus contraction)(hard) (soft) Uterus recovery (Fundus) 惡 露 量 (amout) 量 (<1 ) 量 (<4 ) 量 (<6 ) 量 () Lochia (color) Perineal wound 尿 狀 Emiction 尿 不 尿 at a.m./p.m. 量 ml Hemorrhoid 不 狀 Activity Baby feeding Breast assessment (feeding method)(breast feeding) (mixed feeding) (formula feeding) 狀 度 (engorgement)(soft) (engorged) (partial engorged)(hurt) 泌 (lactation) 泌 (non) 泌 (a little) 泌 (a few) 泌 (plenty) (stretchiness) 良 (well) 不 良 (not well) (intact)(intact) 红 (sore nipple) 裂 (cracked)(dryness or crust) 暈 (vertigo) (pain) (others) (anxiety) (others) 說 A. 了 B. 了 C. 不 了 A B C 錄 (special problem) 療 (medical / nursing intervention) 錄

13 歷 臨 錄 Clinical Care Guideline Record of N.S.D. 3 rd. Day Postpartum 年 11 / 復 (uterus contraction)(hard) (soft) Uterus recovery (Fundus) 惡 露 量 (amout) 量 (<1 ) 量 (<4 ) 量 (<6 ) 量 () Lochia (color)(brown) Perineal wound 尿 狀 Emiction 尿 不 尿 at a.m./p.m. 量 ml 便 Bowel pattern Hemorrhoid 不 狀 Activity Baby feeding Breast assessment (feeding method)(breast feeding) (mixed feeding) (formula feeding) 狀 度 (engorgement)(soft) (engorged) (partial engorged)(hurt) 泌 (lactation) 泌 (non) 泌 (a little) 泌 (a few) 泌 (plenty) (stretchiness) 良 (well) 不 良 (not well) (intact)(intact) 红 (sore nipple) 裂 (cracked)(dryness or crust) 暈 (vertigo) (pain) (others) (anxiety) (others) 說 A. 了 B. 了 C. 不 了 A B C 六 錄 (special problem) 療 (medical / nursing intervention) 錄

14 歷 臨 錄 復 Clinical Care Guideline Record of N.S.D. Postpartum 8 / date/time TPR (//) BP ( mmhg) Uterus contraction () Fundus ( Fb) 惡 露 lochia ( 量 ) 尿 emiction Signature 年 / 4 年 年 年 年 年 年 年 年 年 錄

15 臨 12 年 年 歷 異 () 異 () A. 便 裂 B. 便 塞 C. 參 便 塞 ()() 異 () E. E1. F. 便 塞 G. 1. 療 療 H. 1. BR.data. I. () 療 異 () J01. 料 料

16 臨 12