安寧療護(hù)評估表《安寧共同照護(hù)表》

安寧療護(hù)評估表》《安寧共同照護(hù)表》AnxietyCareAssessmentFormNursingCarePlanforAnxietyCare1.SuggestionsforPainTreatmentMedications:□None□Yes□Forcancerpain:Acetaminophen□NSAID□Tramadol□Demerol□Codeine□Morphine□AdjuvantOther__________________Forbreakthroughpain:□None□Yes________________________PreventiveMeasuresforConstipation:□None□Enema□Medication□Other___________________2.SuggestionsforAssistingintheManagementofOtherSymptoms:□Drugtherapy:suchas____________________□Palliativechemotherapy□PalliativeradiotherapyNursingCare:□Spraytreatment□Edemamassage□Abdominalmassage□Wounddressingchange□OtherPatientEducation:□Dietaryguidance□Rehabilitationguidance□OtherguidanceComfortCare:□Repositioning□Turningandpositioninginbed□Bedbath□Hairwashing□Footcare□Relaxationtherapy□Skincare□Oralcare□PassiveexerciseOther___________________3.CareforPsychosocialProblems:Patient:□Supportandlistening□Referral□Provideappropriatetreatment___________________Family:□Supportandlistening□Referral□Provideappropriatetreatment___________________4.SpiritualandReligiousNeedsCare:Patient:□Lifereview□Discussionofthemeaningoflife□Repairinginterpersonalrelationships□Deepeningreligiousbeliefs□Religiousritualimplementation□Post-eventarrangements□Assistinginachievingwishes□Referraltootherservices_______Family:□Lifereview□Discussionofthemeaningoflife□Repairinginterpersonalrelationships□Deepeningreligiousbeliefs□Religiousritualimplementation□Post-eventarrangements□Assistinginachievingwishes□Referral□Other___________________5.AssistingPatientsinUnderstanding:Patient:□Diagnosis□IllnessandPrognosis□DNRSignature___Family:□Diagnosis□IllnessandPrognosis□DNRSignature___6.AssistingintheDecision-MakingoftheCarePlan:TubePlacementChoices(□Endotrachealtube□NGtube□Foley□Chest□Tube/Pigtail□PEG/Gastrostomy/Jejunostomy□Tracheostomy□Other__________________)NutritionandFluidChoices:(□TPN□IVfluidbloodtransfusion□Other__________________)MedicationChoices:(□Antibiotics□Sedatives□Opioids□Steroids□Other__________________)了解與后事準(zhǔn)備缺乏□無法評估□其他_______4.照護(hù)計劃：A.疼痛控制：□持續(xù)性疼痛：□無□有藥物：□acetaminophen□NSAID□tramadol□demerol□codeine□morphine□adjuvant□其他_____________________________________________________□間歇性疼痛：□無□有藥物：□acetaminophen□NSAID□tramadol□demerol□codeine□morphine□adjuvant□其他_____________________________________________________B.便秘控制：藥物：□laxative□enema□其他_______________________________C.呼吸困難控制：藥物：□oxygen□morphine□其他______________________________D.惡心嘔吐控制：藥物：□ondansetron□metoclopramide□haloperidol□dexamethasone□其他_________________E.瞻望躁動控制：藥物：□haloperidol□lorazepam□其他________________________F.其他癥狀控制：藥物：_____________________________________________________G.心理社會支持：□心理咨詢□社工服務(wù)□宗教支持□其他________________________H.安寧照顧場所：□家庭□醫(yī)院□臨終關(guān)懷中心□其他____________________________I.其他：____________________________________________________________照護(hù)計劃表姓名：年齡：性別：床號：身份：□自費(fèi)□保健照顧日期：年月日照顧時間：自□□：□□至□□：□□主要癥狀：病人ECOG評分：_______分疼痛強(qiáng)度評分：_______分持續(xù)性疼痛：□無□有藥物：_____________________________________________________間歇性疼痛：□無□有藥物：_____________________________________________________便秘評分：最嚴(yán)重_______分藥物：_____________________________________________________呼吸困難評分：最嚴(yán)重_______分藥物：_____________________________________________________惡心嘔吐評分：最嚴(yán)重_______分藥物：_____________________________________________________瞻望躁動評分：最嚴(yán)重_______分藥物：_____________________________________________________其他癥狀：□意識不清□虛弱疲乏□食欲不振□輕度潰瘍□腹瀉□腹脹□腹水□腸梗阻□打嗝□咳嗽□上腔靜脈壓迫癥狀群□水腫□血尿□貧血□皮膚癢□大小便失禁□尿意滯留□里急后重□腫瘤潰瘍□傷口□出血□眩暈□吞咽困難□脊髓壓迫□壓瘡□感染□發(fā)燒□失眠□瀕死癥狀□其他_______心理社會問題：病人：□情緒困擾□疾病認(rèn)知與適應(yīng)困難□家庭互動溝通問題□經(jīng)濟(jì)資源支持系統(tǒng)缺乏□心愿未了與后事準(zhǔn)備缺乏□其他_______家屬：□情緒困擾□疾病認(rèn)知與適應(yīng)困難□家庭互動溝通問題□經(jīng)濟(jì)資源支持系統(tǒng)缺乏□心愿未了與后事準(zhǔn)備缺乏□其他_______照護(hù)計劃：A.疼痛控制：持續(xù)性疼痛：□無□有藥物：_____________________________________________________間歇性疼痛：□無□有藥物：_____________________________________________________B.便秘控制：藥物：_____________________________________________________C.呼吸困難控制：藥物：_____________________________________________________D.惡心嘔吐控制：藥物：_____________________________________________________E.瞻望躁動控制：藥物：_____________________________________________________F.其他癥狀控制：藥物：__