For medical staff, the nursing aspect of patients is particularly important, and today we will sort out the patient's admission and discharge care for everyone.
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<h1 class="pgc-h-arrow-right" data-track="6" > care of admitted patients</h1>
The purpose of patient care in hospitalization is to assist patients to understand and familiarize themselves with the environment so that they can adapt to hospital life as soon as possible; Meet their physical and mental needs and mobilize the enthusiasm of patients to cooperate with treatment and care; Do a good job in health education and promote its early recovery.
(1) Nursing care in the inpatient area
1. Admission procedures The patient or family member holds a hospitalization certificate issued by an outpatient or emergency doctor to the inpatient office for admission procedures. After receiving a patient at the inpatient, the ward is immediately notified by phone to prepare for the reception of new patients.
2. Carry out hygienic treatment According to the patient's condition and physical condition, nurses carry out hygienic treatment in the sanitary disposal room, such as haircuts, bathing, changing clothes, trimming fingernails (toe) nails, etc. For critical, acute and severe patients and those about to give birth, baths may be exempted as appropriate. For those who have lice and lice, the lice are first treated with lice, and then hygienic disposal is carried out. Patients with infectious or suspected infectious diseases should be sent to the isolation room for disposal. Valuables and the patient's changed clothes are handed over to the family to take back, or temporarily stored in the hospital as procedures are followed.
3. Escort the patient into the ward The nursing staff of the inpatient place escorts the patient into the ward with the outpatient medical records. Depending on the patient's condition, it can be walked, or escorted by wheelchair, flat car or stretcher. During the escort process, attention should be paid to safety and warmth, and necessary treatment (such as infusion, oxygen inhalation, etc.) cannot be interrupted; Trauma patients should pay attention to the recumbent position. After escorting the patient into the ward, it is necessary to hand over to the nurse on duty in the ward, including the patient's condition, personal hygiene, and belongings.
(2) Preliminary care of the patient after entering the ward
1. General patient care
(1) Bed preparation unit: After the nurse in the ward receives the notice from the inpatient, she should immediately prepare the bed unit according to the condition. Prepare all the required materials, change the spare bed into a temporary empty bed, and add rubber sheets and medium sheets as appropriate. Patients with infectious diseases should be placed in an isolation ward.
(2) Greet new patients: Nurses should warmly and actively greet new patients, and introduce themselves, place patients in designated beds, and introduce roommates to patients.
(3) Notify the doctor to examine the patient and assist in the examination if necessary.
(4) Measure body temperature, pulse, breathing, blood pressure and weight and record.
(5) Introduction and guidance: Introduce the ward environment, work and rest time, relevant rules and regulations, bed units and equipment use methods to patients and their families. Guide the method, time, and precautions for routine specimen retention.
(6) Fill in the relevant forms
1) Fill in the inpatient record header column and various forms page by page with blue and black ink or carbon ink pen.
2) Use a red water pen to fill in the admission time column between the horizontal line of the temperature sheet 40 ~ 42 ° C, and fill in the admission time in a vertical row.
3) Arrange inpatient medical records in order: temperature list, medical order list, admission record, medical history and physical examination list, medical course record, various inspection report sheets, nursing record sheets, inpatient medical records home page, outpatient or emergency medical records.
4) Fill in the admission registration book, diagnostic card (inserted in the patient's hospitalization list), bedside card (inserted in the bedside or bedside tag).
(7) Correctly implement the doctor's instructions and notify the dining room to prepare meals for the patient.
(8) Patiently listen to and answer the patient's consultation, conduct the admission nursing assessment, and fill in the admission nursing evaluation form.
2. Care of emergency patients
(1) Bed preparation unit: After receiving the notice, if the nurse in the ward receives the notice, if it is an acute and critically ill patient, the bed unit should be prepared immediately in the critical ward or the rescue room, and the rubber sheet and the middle single should be laid as needed, and the anesthesia bed should be prepared for emergency surgery patients.
(2) Make rescue preparations: Prepare first-aid equipment and medicines, and notify the doctor to make rescue preparations.
(3) Careful handover: After the patient enters the ward, the nurse should immediately hand over with the escort inmate, and for patients with language impairment, unconscious patients or infants and young children, etc., need to stay with the accompanying staff in order to ask for medical history.
(4) Cooperate with rescue: After the patient enters the ward, he should closely observe the changes in the condition, actively cooperate with the rescue, and make a good nursing record.
<h1 class="pgc-h-arrow-right" data-track="43" > care of discharged patients</h1>
The purpose of discharge care is to provide discharge guidance to patients, meet their physical and mental needs, and assist them in adapting to social life as soon as possible;
(1) Nursing care before discharge
(2) Handling of relevant documents
1. Fill in the discharge time with a red water pen in the corresponding time column between the 40 and 42 horizontal lines of the body temperature list, and fill in the discharge time in a vertical line.
2. Cancel the card To cancel various cards, such as diagnostic cards, bedside (tail) cards, medication cards, diet cards, treatment cards, etc.
3. Sort out the discharge medical records and sort out the medical records, and submit them to the case room for preservation. The medical | education network collects and sorts out the order of discharge medical records: the first page of inpatient medical records, discharge (or death) records, admission records, medical history and physical examination lists, medical course records, various examination and examination reports, nursing records, medical orders, and temperature lists.
4. Fill in the patient discharge registration book.
(3) Handling of bed units
1. Remove the dirty clothes on the hospital bed, put them into the dirty clothes bag, and send them to the laundry room for treatment.
2. Mattresses, mattresses, cotton tires, pillow cores are disinfected with ultraviolet light or exposed to sunlight for 6 hours.
3. The bed and the table and chair next to the bed are wiped with disinfectant solution; non-disposable washbasins and sputum cups are soaked with disinfectant solution.
4. Open the window of the ward for ventilation.
5. Make a spare bed and prepare to meet new patients.
6. The ward and bed unit of patients with infectious diseases shall be treated according to the terminal disinfection method of infectious diseases.