新竹CCU生存日常

新病人(住院/病房轉入都算)

• 連到Webhis(員編：H00000;密碼：身分證字號)
• 完成加護病房轉入表單，儲存完複製到Progress Note
  • 轉出當日，循同樣步驟完成加護病房轉出表單，儲存完複製到Progress Note

交班

• 每天下午 17:00 前請至院內 NAS→內科部→填寫 內科部交班單
• NAS:\\172.23.48.31\內科部
• NAS 內科部帳號密碼:internal/internal

導管後過夜觀察病人

• 轉入時，填寫導管後加護病房轉入記錄
• 轉出時，填寫導管後加護病房轉出記錄

<Problem list>

1. Coronary artery disease, three-vessel-disease, status-post plain old balloon angioplasty and intracoronary stenting(POBAS) to left anterior descending artery / left circumflex artery / right coronary artery (2016/09/08)

2. Non-ST elevation myocardial infarction, TIMI score

<Assessment>

(Date) presented to our ER due to chest pain for xx hours

<PE>

GCS E4V5M6

Head: pink conjunctiva, anicteric sclera

Neck: JVE(+)

Chest: bilateral clear brething sound

Heart: regular heart beat, no obvious murmur

Abdomen: soft, normoactive bowel sound, no tenderness

Limbs: edema(-)

<Important Study Findings>

(Date) EKG:

(Date) CK/CK-MB/Troponin-T: ()/()/()

(Date) CK peaking at

(Date) UCG:

(Date) CAG:

<Important Intervention and Newly Added medicationI>

(Date) PCI

(Date) TPM

(Date) PPM

<Important family's decision>

Nil

<Plans>

1. For coronary artery disease, s/p PCI

=> Prepare for coronary angiography

=> CAD risks stratification

=> Keep DAPT, beta-blocker, ACEi/ARB, statin for CAD

=> Post-CATH wound care

=> Informed consent and explain further care plain