住院患者护理评估表.doc

Nursing assessment form of inpatientMedical category Bed number Name Age years old Admission number Diagnosis Part one The first assessment1、 The assessment of the risk for bedsores :Norton scale: points or Braden scale: points No bedsore Existing bedsores:the part of the bedsores and staging Nursing measures ： air bed preventive decompression paste sanyrene turn over Q h Other measures 2、The assessment of the risk for falling down or falling outofbed : The falling down scale： points Nursing measures ： strengthen health education sign warning three steps of Getting up use the toilet The correct use of bed bar medication guide keep lighting strict bed rest Other measures 3、The assessment of the risk for catheter： no existing：into catheter of low risk catheter of middle risk catheter of high risk Catheter scale ： points Nursing measures：strengthen health education sign warning put the pipe id properrestraintOther measures 4、Pain assessment：pain score： points Nursing measures ： mental nursing relieve pain by physical method relieve pain by painkiller Other measures 5、Nutrition assessment： The Screening assessment of risk for nutrition： points Nursing measures ： enteral nutrition parenteralnutrition Other measures 6、The assessment of self-help ability:ADL scale: points The nurse signature ： / / Part two Interim evaluation 1、The assessment of the risk for bedsores DateNorton/Braden scalethe part of the bedsores and stagingNursing measuresSign-atureDateNorton/Braden scalethe part of the bedsores and stagingNursing measuresSign-ature Nursing measures ：air bed;preventive decompression paste;sanyrene; turn over Q1-2h;other measures.2、 The assessment of the risk for falling down or falling out of bed ：DateThe falling down scaleNursing measuresSignatureDateThe falling down scaleNursing measuresSignatureNursing measures : strengthen health education;sign warning;three steps of getting up; use the toilet; the correct use of bed bar;medication guide; keep lighting;strict bed rest;other measures.3、 The assessment of the risk for catheter：DateCatheter scaleNursing measuresSignatureDateCatheter scaleNursing measuresSignatureNursing measures：strengthen health education;sign warning; put the pipe id;properrestraint;other measures .4、 Pain assessment：TimePositionPain scoreNursing measuresSignatureTimePositionPain scoreNursing measuresSignature Nursing measures :mental nursing;relieve pain by physical method ; relieve pain by painkiller;other measures.5、Nutrition assessment：DateNutritionscoreNursing measuresSignatureDateNutritionscoreNursing measuresSignatureNursing measures ：enteral nutrition;parenter