手術(shù)計(jì)劃登記表范本

手術(shù)計(jì)劃登記表范本手術(shù)計(jì)劃登記表范本一、基本信息手術(shù)日期：____________________手術(shù)科室：____________________手術(shù)醫(yī)生：____________________術(shù)前主管護(hù)士：____________________病人姓名：____________________病人性別：____________________病人年齡：____________________病人住院號(hào)：____________________病人電話號(hào)碼：____________________病人病區(qū)：____________________病人診斷：____________________二、手術(shù)類型主要手術(shù)：____________________輔助手術(shù)：____________________聯(lián)合手術(shù)：____________________手術(shù)部位：____________________手術(shù)等級(jí)：____________________手術(shù)持續(xù)時(shí)間：____________________手術(shù)風(fēng)險(xiǎn)：____________________三、術(shù)前準(zhǔn)備1.患者準(zhǔn)備：a.患者飲食：禁食時(shí)間____________________b.患者排便：清潔腸道，口服瀉藥____________________c.患者洗澡：使用抗菌皂，清潔手術(shù)部位____________________d.患者皮膚準(zhǔn)備：使用消毒劑消毒手術(shù)部位____________________e.患者穿戴：穿著手術(shù)衣，佩戴手術(shù)帽，口罩，鞋套等____________________2.設(shè)備準(zhǔn)備：a.手術(shù)器械：準(zhǔn)備所需手術(shù)器械和設(shè)備____________________b.特殊設(shè)備：準(zhǔn)備可能需要的特殊設(shè)備____________________c.消毒器械：對(duì)手術(shù)器械進(jìn)行消毒和滅菌處理____________________3.藥品準(zhǔn)備：a.麻醉藥品：準(zhǔn)備所需麻醉藥品和輔助藥品____________________b.抗生素：術(shù)前使用抗生素預(yù)防感染____________________c.其他藥品：根據(jù)需要準(zhǔn)備其他藥品____________________四、術(shù)中操作1.麻醉方式：選擇適合的麻醉方式____________________2.手術(shù)部位準(zhǔn)備：再次使用消毒劑消毒手術(shù)部位____________________3.手術(shù)操作步驟：a.開(kāi)始手術(shù)：記錄手術(shù)開(kāi)始時(shí)間____________________b.切口：描述手術(shù)切口的位置和方式____________________c.操作過(guò)程：詳細(xì)記錄手術(shù)操作的步驟和方法____________________d.術(shù)中問(wèn)題：記錄術(shù)中可能出現(xiàn)的問(wèn)題和處理方法____________________e.手術(shù)時(shí)間：記錄手術(shù)持續(xù)時(shí)間____________________五、術(shù)后處理1.手術(shù)結(jié)束：記錄手術(shù)結(jié)束時(shí)間____________________2.手術(shù)切口處理：修復(fù)和清潔手術(shù)切口____________________3.麻醉恢復(fù)：觀察患者麻醉恢復(fù)情況____________________4.術(shù)后護(hù)理：指導(dǎo)患者術(shù)后護(hù)理和注意事項(xiàng)____________________5.輸血處理：記錄輸血情況和處理結(jié)果____________________6.拍片檢查：記錄術(shù)后拍片檢查結(jié)果____________________六、術(shù)后隨訪1.術(shù)后隨訪時(shí)間：規(guī)定術(shù)后隨訪的時(shí)間點(diǎn)____________________2.術(shù)后隨訪內(nèi)容：記錄術(shù)后隨訪的具體內(nèi)容和要求____________________3.術(shù)后并發(fā)癥：記錄術(shù)后可能出現(xiàn)的并發(fā)癥和處理方法____________________七、風(fēng)險(xiǎn)評(píng)估1.術(shù)前風(fēng)險(xiǎn)評(píng)估：對(duì)手術(shù)前的風(fēng)險(xiǎn)進(jìn)行評(píng)估____________________2.術(shù)中風(fēng)險(xiǎn)評(píng)估：對(duì)手術(shù)中的風(fēng)險(xiǎn)進(jìn)行評(píng)估____________________3.術(shù)后風(fēng)險(xiǎn)評(píng)估：對(duì)術(shù)后的風(fēng)險(xiǎn)進(jìn)行評(píng)估____________________八、術(shù)后總結(jié)1.手術(shù)結(jié)果：記錄手術(shù)的結(jié)果和效果____________________2.術(shù)后評(píng)價(jià)：對(duì)手術(shù)過(guò)程和結(jié)果進(jìn)行評(píng)價(jià)____________________3