手術(shù)患者術(shù)前訪視記錄附有答案

手術(shù)患者術(shù)前訪視記錄[復(fù)制]基本情況1.患者姓名[填空題]*_________________________________2.性別[單選題]*○男○女3.年齡[填空題]*_________________________________4.本次住院ID號[填空題]*_________________________________5.科室[單選題]*○骨一科○骨二科○骨三科○骨四1科○骨四2科○普外科○泌尿外科○胸外科○婦科○產(chǎn)科○ENT○神經(jīng)外科○眼科○其他6.診斷[填空題]*_________________________________7.擬定術(shù)式[填空題]*_________________________________8.體位[填空題]*_________________________________重要信息9.手術(shù)醫(yī)囑[單選題]*○開具○未開具10.安全核查單[單選題]*○打印○未打印11.住院患者授權(quán)委托書[單選題]*○簽署○未簽署12.既往病史[多選題]*□高血壓_________________□冠心病_________________□糖尿病_________________□其他1_________________□其他2_________________□體健13.手術(shù)史[多選題]*□無□手術(shù)史1_________________□手術(shù)史2_________________□手術(shù)史3_________________14.體內(nèi)植入物[單選題]*○無○有_________________15.HIV檢測[單選題]*○陰性○陽性○未回報○未化驗_________________16.梅毒檢測[單選題]*○陰性○陽性○未回報○未化驗_________________17.乙肝檢測[單選題]*○陰性○陽性_________________○未回報○未化驗_________________18.HbsAg[單選題]○陽性○陰性19.丙肝檢測[單選題]*○陰性○陽性○未回報○未化驗_________________20.血型[填空題]_________________________________21.患者[單選題]*○未在○外出檢查○在病室術(shù)前評估22.意識狀態(tài)[單選題]○意識清楚○意識模糊23.營養(yǎng)狀況[單選題]○正?！鸱逝帧鹣荨馉I養(yǎng)不良○其他_________________24.藥物過敏史[單選題]*○無○有_________________(請?zhí)恋?5題)○曾經(jīng)發(fā)生過敏癥狀不知曉何種藥物所致25.過敏癥狀[填空題]_________________________________26.食物過敏史[單選題]*○無○有_________________(請?zhí)恋?7題)○曾經(jīng)發(fā)生過敏癥狀不知曉何種食物所致27.過敏癥狀[填空題]_________________________________28.心理狀況[單選題]○平靜○緊張○恐懼○焦慮○其他_________________29.語言溝通[單選題]○正常○障礙_________________30.肢體活動[單選題]○靈活○活動受限_________________○關(guān)節(jié)僵直_________________31.全身皮膚[多選題]□完整□破損_________________□壓力性損傷_________________□紋身_________________壓力性損傷32.壓力性損傷部位[填空題]_________________________________33.分期[單選題]○1期：指壓不變白紅斑，皮膚完整○2期：部分皮層缺失伴真皮層暴露○3期：