MindMap Gallery Delivery room medical record report
This is a mind map about delivery room medical records. The main contents include: condition introduction, patient basic information, medical history, diagnosis, treatment, nursing and other aspects, providing doctors with important diagnostic and treatment references.
Edited at 2025-01-26 12:14:00Rumi: 10 dimensions of spiritual awakening. When you stop looking for yourself, you will find the entire universe because what you are looking for is also looking for you. Anything you do persevere every day can open a door to the depths of your spirit. In silence, I slipped into the secret realm, and I enjoyed everything to observe the magic around me, and didn't make any noise. Why do you like to crawl when you are born with wings? The soul has its own ears and can hear things that the mind cannot understand. Seek inward for the answer to everything, everything in the universe is in you. Lovers do not end up meeting somewhere, and there is no parting in this world. A wound is where light enters your heart.
Chronic heart failure is not just a problem of the speed of heart rate! It is caused by the decrease in myocardial contraction and diastolic function, which leads to insufficient cardiac output, which in turn causes congestion in the pulmonary circulation and congestion in the systemic circulation. From causes, inducement to compensation mechanisms, the pathophysiological processes of heart failure are complex and diverse. By controlling edema, reducing the heart's front and afterload, improving cardiac comfort function, and preventing and treating basic causes, we can effectively respond to this challenge. Only by understanding the mechanisms and clinical manifestations of heart failure and mastering prevention and treatment strategies can we better protect heart health.
Ischemia-reperfusion injury is a phenomenon that cellular function and metabolic disorders and structural damage will worsen after organs or tissues restore blood supply. Its main mechanisms include increased free radical generation, calcium overload, and the role of microvascular and leukocytes. The heart and brain are common damaged organs, manifested as changes in myocardial metabolism and ultrastructural changes, decreased cardiac function, etc. Prevention and control measures include removing free radicals, reducing calcium overload, improving metabolism and controlling reperfusion conditions, such as low sodium, low temperature, low pressure, etc. Understanding these mechanisms can help develop effective treatment options and alleviate ischemic injury.
Rumi: 10 dimensions of spiritual awakening. When you stop looking for yourself, you will find the entire universe because what you are looking for is also looking for you. Anything you do persevere every day can open a door to the depths of your spirit. In silence, I slipped into the secret realm, and I enjoyed everything to observe the magic around me, and didn't make any noise. Why do you like to crawl when you are born with wings? The soul has its own ears and can hear things that the mind cannot understand. Seek inward for the answer to everything, everything in the universe is in you. Lovers do not end up meeting somewhere, and there is no parting in this world. A wound is where light enters your heart.
Chronic heart failure is not just a problem of the speed of heart rate! It is caused by the decrease in myocardial contraction and diastolic function, which leads to insufficient cardiac output, which in turn causes congestion in the pulmonary circulation and congestion in the systemic circulation. From causes, inducement to compensation mechanisms, the pathophysiological processes of heart failure are complex and diverse. By controlling edema, reducing the heart's front and afterload, improving cardiac comfort function, and preventing and treating basic causes, we can effectively respond to this challenge. Only by understanding the mechanisms and clinical manifestations of heart failure and mastering prevention and treatment strategies can we better protect heart health.
Ischemia-reperfusion injury is a phenomenon that cellular function and metabolic disorders and structural damage will worsen after organs or tissues restore blood supply. Its main mechanisms include increased free radical generation, calcium overload, and the role of microvascular and leukocytes. The heart and brain are common damaged organs, manifested as changes in myocardial metabolism and ultrastructural changes, decreased cardiac function, etc. Prevention and control measures include removing free radicals, reducing calcium overload, improving metabolism and controlling reperfusion conditions, such as low sodium, low temperature, low pressure, etc. Understanding these mechanisms can help develop effective treatment options and alleviate ischemic injury.
Delivery room medical record report
Basic patient information
Bed number Name Age
Main complaint
Admission diagnosis Admission time
Introduction to the condition
Current medical history
Cause of hospitalization (because of … admission)
Pregnancy situation
Diet, sleep, urination, activity, psychology, etc.
Personal history related to illness, pregnancy history
Special circumstances of pregnancy and childbirth
Meaningful past history, medication, and food allergy history
Admission assessment (positive result)
Vital signs are normal (or positive results are reported)
Specialty status (fetal position, uterine height, abdominal circumference, fetal heartbeat, fetal movement, vaginal examination (pelvic, cervical scoring, fetal membrane, amniotic fluid)
Positive auxiliary test results
Positive items for each system
Treatment
Post-admission diagnosis and treatment nursing plan (blue description: nursing level, ×× diet, diagnosis and treatment nursing (viral sign monitoring frequency, fetal heart and fetal movement monitoring, special medication)
Treatment
Briefly describe the patient's condition changes
Current situation
Prenatal
The reason for entering the delivery room...
Current situation: Assessment: mental, emotional, vital signs, breast, perineum, vaginal bleeding, urination, contraction, fetal heart, fetal membrane, vaginal examination (pelvis, cervix, and pre-exposed position, Membrane condition, amniotic fluid (quantity, color)
Positive results for auxiliary examination (blood routine, blood coagulation, four preoperative terms, liver and kidney function, B group, ultrasound, etc.)
Positive results were evaluated in each system
Nursing issues: first-class, medium-class, and sub-optimal (nurturing issues, expected goals, nursing measures, and effectiveness evaluation)
Postpartum
Delivery status
Special circumstances during delivery
Specialties: placental membrane, amniotic fluid, bleeding volume, breast, perineal wound, vaginal bleeding
Treatment: Nursing, diet, vital sign monitoring, medication
Current situation
Vital signs (normal range)
Assessment status: mental, mood, breasts, contractions, incisions, perineum, vaginal bleeding, activity and other positive signs and tests, risk assessment positive items
Nursing issues: first-class, medium-class, and sub-optimal (nurturing issues, expected goals, nursing measures, and effectiveness evaluation)