患者自行拔出尿管,有少量出血,如何书写护理记录 护理安全：患者自行拔出尿管
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\u6837\u4f8b
01\u8f6c\u5165\u62a4\u7406\u8bb0\u5f55
\u75c5\u4eba\u4e8e14\uff1a00\u7531\u5185\u56db\u79d1\u8f6c\u5165\u6211\u79d1\uff0c\u62c5\u67b6\u62ac\u5165\u75c5\u623f\uff0c\u7531\u5185\u56db\u79d1\u5e26\u5165\u7559\u7f6e\u5c3f\u7ba1\u3001\u7559\u7f6e\u80c3\u7ba1\u3001\u5957\u7ba1\u9488\uff0c\u60a3\u8005\u795e\u5fd7\u604d\u60da\u3001\u989c\u9762\u6d6e\u80bf\uff0c\u53cc\u7403\u7ed3\u819c\u6c34\u80bf\uff0c\u6d4b\u8840\u7cd611.1mmol/L\uff0cT37.7p92\u6b21/\u5206R20\u6b21/\u5206Bp140/80mmhg
02\u8f6c\u51fa\u62a4\u7406\u8bb0\u5f55
T36\uff0cP86\u6b21/\u5206\uff0cR20\u6b21/\u5206\uff0cBp120/80mmHg\u3002\u8a00\u8bed\u6d41\u5229\uff0c\u56db\u80a2\u808c\u529b\u7ea7\uff0c\u5468\u8eab\u76ae\u80a4\u5b8c\u597d\u3002\u5fc3\u7535\u76d1\u62a4\u793a\uff1a\u5fc3\u738786\u6b21/\u5206\uff0c\u5f8b\u4e0d\u9f50\uff0c\u623f\u98a4\u3002\u81ea\u8bc9\uff1a\u201c\u5fc3\u614c\u3001\u80f8\u95f7\u3002\u201d\u957f\u5631\u8f93\u6db2\u5df2\u7ed3\u675f\uff0c\u4e8e3L/min\u5438\u6c27\u4e2d\u3002\u9075\u533b\u5631\u8f6c\u5f80\u5fc3\u5185\u79d1\uff0c\u643a\u5e26\u6c27\u6c14\u888b\uff0c\u62a4\u9001\u524d\u5f80\u3002
03\u8f93\u8840\u62a4\u7406\u8bb0\u5f55
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04\u51fa\u9662\u62a4\u7406\u8bb0\u5f55
\u60a3\u8005XXX\uff0c\u7537\uff0cXX\u5c81\uff0c\u4ee5\u80c6\u7ed3\u77f3\u4e8eX\u5e74X\u6708X\u65e5\u5165\u9662\uff0c\u4e8eX\u6708X\u65e5\u5728\u5168\u9ebb\u4e0b\u884c\u8179\u8154\u955c\u80c6\u56ca\u6458\u9664\u672f\uff0c\u672f\u540e\u5404\u9879\u62a4\u7406\u63aa\u65bd\u5230\u4f4d\uff0c\u60a3\u8005\u4eca\u65e5\u8981\u6c42\u51fa\u9662\uff0c\u5631\u5176\u51fa\u9662\u540e\u6ce8\u610f\u4f11\u606f\uff0c\u8fdb\u6e05\u6de1\u996e\u98df\uff0c\u7981\u98df\u80a5\u7518\u539a\u817b\u4e4b\u54c1\uff0c\u4fdd\u6301\u5fc3\u60c5\u8212\u7545\u4ee5\u5229\u809d\u6c14\u901a\u8c03\u8fbe\uff0c\u6c14\u8840\u8c03\u548c\u3002\u60a3\u8005\u53ca\u5bb6\u5c5e\u8868\u793a\u4e86\u89e3\u3002
\u2014 THE END \u2014
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患者自行拔除尿管，报告医生。尿管壁完整，患者无诉不适 ，予以继续观察并书写不良事件报告单。
护理文件书写的原则
一、总体要求
客观、准确、及时、完整、连续、合法。内容上要求：详略得但当、条理清晰、用词恰当。
二、客观性
要求做到：看到什么记什么，做什么记什么，有什么记什么，流水账，客观存在的事实，不要硬性找问题。不对病人情况进行主观分析，记录患者的客观资料。
三、准确性
要求数据准确，药物的量，引流液的色量，生命体征的数据均要准确无误。
扩展资料：
医疗文件的意义
1、诊断治疗护理的依据 病案是医务人员临床初中的原始记录文件，完整的病案记录是诊断、治疗、护理的重要依据。当病人出现危急情况，或再次入院治疗时，都需要根据既往的病案资料加以综合判断分析，才能作出正确的处理。
2、医院管理考核的重要信息和参考 病案的书写与记录可反映医院的服务质量和技术水平，它既是医院管理的重要信息，又是考核医护人员的参考资料。
3、医学统计的原始记录 病案资料是医学统计的原始记录，可提供防病治病和流行病学的调查。
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