It is a subsystem of nursing management system. With the development of medicine, the research scope of nursing is getting wider and wider, and the problems faced by clinical nursing are also increasing. Therefore, it is necessary to carry out clinical nursing rounds. In addition, the nursing ward round system is one of the core nursing systems. In order to improve the nursing level of the whole hospital and standardize the core nursing system, it is necessary to organize nursing rounds. Nursing ward round is the most basic, commonly used and main method to evaluate the implementation effect of nursing procedures and understand the nature of nurses' work in nursing management.
2 nursing ward round process editing
(1) Director explained the purpose of rounds.
(2) The responsible nurse reports the patient's situation, focusing on the existing nursing diagnosis/problems, nursing plan, nursing measures taken, nursing effects achieved and nursing diagnosis/problems to be solved.
(3) Nursing physical examination. According to the report of the responsible nurse and the record of the nursing medical record, the main examiner asks the patient and carries out the nursing physical examination.
(4) Evaluation and guidance. According to the information obtained, such as the patient's nursing diagnosis/problems, the implementation of nursing plan and other related issues, the chief researcher organizes nurses to discuss and evaluate.
3 nursing ward round records for example editing
Example 1: nursing ward round record
Time: May 2006 10
Number of participants: 10.
Investigator: Wang * *
Patient bed number: 15 bed.
Patient name: Sun * *
Diagnosis: hypertensive cerebral hemorrhage
Main contents:
1. The nurse in charge briefly described the process of the disease.
2. The nurse in charge reports the patient's nursing problems.
3. Nursing points of ventricular drainage.
4. The patient's healthy side, paralyzed side and supine position are correct.
5. Turn over for hemiplegic patients (actually operated by two people).
6. Paralyzed limb function exercise (responsible for nurse demonstration).
7. Health education evaluation: Ask the patients' families how to prevent constipation. Physical function exercise (practical exercise).
Example 2: Nursing rounds record
Date: 2 June 20061
Number of participants: 10.
Investigator: Wang * *
Patient's bed number: bed 23.
Patient name: Sun * *
Diagnosis: Brain hernia due to brain trauma.
Main contents:
1. The nurse in charge briefly described the course of the disease (eight know)
2. The nurse in charge reports the patient's nursing problems.
3. Observation and nursing of common complications in the early stage of tracheotomy.
4. Turn over, knock on the back and suck sputum.
5. Key points of airway management.
6. Basic nursing quality evaluation: three short and six clean, lying position, bed unit.
7. Ask students: nasal feeding methods and precautions.
8. Health education evaluation: ask the patient's family members about physical function exercise (actual operation).