英文--护理评估单as.docx

英文--护理评估单as

第一篇：英文--护理评估单asWuhanUnionHospitalofChinaFirstnursingevaluationsheetofin-patientLevelofeducation:□illiterate□primaryschool□middleschool□seniormiddleortechnicalsecondaryschool□juniorcollege□undergraduateandaboveAdmissionform:□walking□Supportedwalking□wheelchair□Flatcar□stretcher□othersFundamentalstateassessmentConsciousness:□clear□sleepiness□confusion□lethargy□comaBodyposition:□activeposition□passiveposition□forcedposition(□orthopneicposition□semi-fowler's□lateralposition□proneposition□others)Skinandmucousmembrane:□normal□pressureulcer□scald□trauma□Diet:□generaldiet□semifluid□fluid□fasting□NGtube□therapeuticaldietCacation:□normal□day;Auxiliary:□no□)□□incontinence□fistulation(ADL:□yes□no)□Urination:□normal□incontinence□urinaryretention□dysuria□retentioncatheteriztion□othersAllergichistory:Medicine:□no□unknown□yesFood:□no□unknown□□Smoking:□no□yesDrinking:□no□occasionally□frequently□everydayADL:□completely□partially□incompetentlyBarthelindex:scoreTumbleriskevaluation:□Tumblehistory□Activityabnormal□Auxiliary-set□Sleepingdisorders□VisionabnormalPainevaluation:□no□)Degreeofpain:□0analgesia□1~3slightlypain□4~6alittlepain□7~9verypain□10sharplypain（score）Pressureulcerrisk(Nortonscore):scoreOthers:Introductionofadmission:□admissionknowledge□environmentandfacilities□relateddoctorandnurse□diet□securitymanagementsystem□tumblepreventionknowledge□relevantknowledgeofdiseaseTime:1st第二篇：外科中医护理评估单入院护理评估单科别_______床号_____住院号________姓名_______性别年龄________籍贯_职业_________文化________婚否______联系电话________入院方式：步行、搀扶、轮椅、平车入院时间______年___月___日_______时记录时间______年___月___日_______时诊断：中医西医管床医生主诉：过敏史:(食物、药物)无有家族史：无有吸烟史：无有_______支/日年饮酒史：无有______ml/日年检查：体温°C脉搏次/分呼吸次/分血压mmHg1、望诊形体：正常肥胖消瘦其它__________________________________________________情绪：开朗焦虑易怒恐惧悲观其它舌苔：薄白薄黄黄苔白苔腻腐白腻黄腻黑苔花剥少苔其它：________________舌质：淡红淡白红降青紫舌尖红齿痕裂纹胖大瘦小其它：__________________望神：有神倦怠萎靡烦躁恍惚谵妄嗜睡昏睡昏迷其它____________________面色：如常红润两颧潮红白苍白菱黄晦暗青紫无光泽其它形态：正常步履蹒跚半身不遂蜷卧不得平卧其它皮肤：色泽：正常恍然红斑紫绀潮红干燥甲错其它完整性：完整丘疹出血点破溃痛疖水肿其它2、闻诊：声音：正常音哑失音谵语呃逆呻吟语音低微喘息气粗咳声无力或