麻醉前沟通记录范文.doc

麻醉前沟通记录范文 麻醉前沟通记录重庆市南川区人民医院麻醉前访视沟通记录姓名性别年龄岁病区床位住院号暂停择期手术沟通为了您手术麻醉过程中的安全，手术麻醉后尽快的康复，手术前麻醉医师会了解您禁食禁水情况、当前的生理条件、用药情况和既往伴随疾病。 同时，您还可以了解麻醉医师在手术过程中将要采取的多种安全预防措施。 在进入手术室前尽管已经做好各项术前准备，但如果因患者存在以下情况之一时，手术麻醉具有极大直接危及生命的风险。 为了您的安全，手术麻醉科会暂停择期手术。 1.未严格禁食禁水（不能吃任何东西）；2.呼吸系统急性上呼吸道感染有咳嗽咳痰症状；未控制的慢性梗阻性肺疾病、支气管哮喘发作；肺炎；3.心血管系统未控制的高血压；已经控制的高血压患者在进入手术室前因恐惧紧张致收缩压超过180mmHg或舒张压超过110mmHg；已经控制的高血压患者在进入手术室后因恐惧紧张致收缩压超过180mmHg或舒张压超过110mmHg，在麻醉医生充分镇静后收缩压仍然超过180mmHg者或伴有高血压头痛、复视等症状；6个月内发生心肌梗塞；未安置临时起搏器的度型、度房室传导阻滞、双束支传导阻滞；未控制的、级不稳定心绞痛；4.内分泌系统血糖未控制的糖尿病患者，血糖超过10mmol/L者，尿糖（+）以上；已经控制较好血糖水平患者术日晨查血糖血糖超过10mmol/L者；在进入手术室后血糖超过10mmol/L者；未控制的甲状腺功能亢进患者；未控制的甲状腺功能不全患者；5.肝功异常，转氨酶超过正常值2倍以上等；严重肾功不全；6.电解质紊乱如钾离子低于3.0mmol/L或高于6.0mmol/L；血钙0.87mmol/L；7.患者合并隐匿性疾病，常规医学检查未检查出，在进入手术室后因恐惧紧张而引发出现心律失常如频发室性早搏、二联律、三联律、多源性室性早搏、心室率大于100次/分的频发房性早搏、房颤等；8.其他未列出的特殊情况及暂停手术原因医保外自费药品或耗材使用沟通手术麻醉过程中因您病情需要而必须使用部分医保外自费药品或耗材而致麻醉费用增加钠石灰口复方利多卡因乳膏口右美托咪定口镇痛泵口有创动脉血压监测传感器口有创中心静脉压监测传感器口以上情况已经与患者及家属从分沟通并已经知晓，并签字表示同意、理解。 患者或家属（签字）与患者关系麻醉医师（签字）沟通时间年月日时分Hq9$Luc*Ox g+SBk3W 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