[問題] 護理紀錄
目前在高雄長庚實習,我寫護理紀錄能否請各位學姐看哪邊不順
寫了三次都被老師退稿…我把老師圈起來有問題的內容用括號表示,
個案36歲,是兩年前車禍左腳踝骨折釘了骨釘,後來住院折除釘子。
目前是術後一天。
0900
病人臥床休息中,意識清楚,生命徵象如上。左下肢腳踝外側傷口約8公分、
內側傷口約3公分,外側傷口有少量血液滲出,無紅腫,依醫囑傷口換藥,給
予生理食鹽水清潔,水溶性優碘消典,紗布覆蓋彈繃使用,未稍血循良好,評
估傷口疼痛指數為3分,性質抽痛,病人表示可忍受。左手有一21號IC針
(寫留置針或是21號IC針都被劃圈)
留置,留置部位無紅腫。今教導傷口護理換藥及傷口注意事項,換藥前後要洗手,
先將棉枝用食鹽水沾濕清潔傷口,再優碘消毒,紗布覆蓋,需注意傷口有無感染情形,
(誰?)
傷口感染有紅腫熱及分泌物等情形,要回門診檢查,傷口部位需保持乾燥,如擦澡時
(紅腫熱) (門診) (燥我寫火部的被圈說是錯字)
傷口部位不能碰觸到水,病患及家屬可了解與配合。
1300
病人臥床睡覺中,呼吸平穩,傷口以彈繃包紮,未肢皮膚顏色粉紅、溫暖、感覺正常與
活動良好,無麻木感。無其它不適情形,家屬陪伴,續觀察。
1500
病人臥於床上閱讀報紙,意識清楚,呼吸平穩。評值衛教內容,病人及家屬可正確
回覆示教,傷口護理換藥及說出傷口換藥的注意事項,如傷口部位需乾燥,及傷口若
(傷口換藥)
出現感染徵象,需回門診。現病人臥床與家屬聊天。
以上就是我的紀錄
不知道哪邊要改還是邏輯怪怪的
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