广东省营养科标准营养病历.doc 7页

姓名： 性别： 家庭住址： 年龄： 民族： 工作单位： 籍贯： 职业： 联系电话： 科室： 床号： 入院日期： ID号： 住院号： 营养治疗时间： 主管科室医生： 主管营养医师： 病史（主诉，现病史）： 既往史及个人史： 临床诊断： 营养专科体格检查 儿童及青少年： 身高： cm 体重： kg 平常体重： kg 头围： cm 胸围： cm 目标体重/身高： kg/cm 成人： 身高： cm 体重： kg 平常体重： kg 腰围： cm 握力： kg 理想体重： kg 上臂围： cm 体质指数： kg/m2 三头肌皮褶厚度： mm 头发： □灰暗 □黄 □稀 □密 □干 □脆 □易断 □秃发 □正常 □其他： 眼结膜/角膜： □充血 □干燥 □苍白 □毕氏斑 □正常 □软化 □溃疡 □正常 □其他： 舌： □猩红色 □舌缘齿痕 □光滑舌 □溃疡 □乳头萎缩 □乳头肥大 □正常 □其他： 齿龈/齿： □充血 □肿胀 □易流血 □苍白 □溃疡 □龋齿 □缺齿少齿 □正常 □其他： 甲状腺： □肿大 □结节 □硬 □软 □正常 □其他： 皮肤： □干燥 □瘀点 □瘀斑 □毛囊角化 □水肿 □黄染 □皮炎 □正常 □其他： 指/趾甲： □反甲 □苍白 □杵状指 □脊状甲 □正常 □其他： 皮下组织： □水肿 □脂肪减少 □脂肪增多 □正常 □其他： 肌肉/骨骼： □肌肉萎缩 □颅骨软化 □前囟未闭 □方颅 □干骺端肥大 □正常 □其他： □鸡胸 □漏斗胸 □肋骨串珠 □“X”形腿 □“O”形腿 □哈氏沟 是否曾服用营养补充剂（种类、剂量、次数、服用持续时间）： 忌食或过敏食物： 营养风险筛查评分：________分 营养评价：□营养状况正常 □轻度营养不良 □中度营养不良 □重度营养不良 营养治疗计划 目标：能量： kcal 蛋白质： g 脂肪： g 碳水化合物： g 水分 ml 营养治疗方案： ※途径：□经口膳食 □肠内 □肠外 经口膳食 ★医院常规膳食：□禁食 □普食 □软饭 □半流质 □流质 ★治疗膳食： □限盐（钠）膳食 □中链甘油三酯膳食 □限饱和脂肪、胆固醇膳食 □限单胺类饮食 □限脂肪膳食 □低嘌呤膳食 □少渣膳食 □高纤维膳食 □高蛋白膳食 □低蛋白膳食 □高能量膳食 □低能量膳食 □正常膳食 □ 肠内 ★肠内营养途径：□经口 □鼻胃管 □鼻十二指肠管 □鼻空肠管 经皮内镜下胃造瘘（PEG） □经皮内镜下空肠造瘘（PEJ） □肠内营养：□要素制剂：□短肽型 □中链甘油三酯型 □特殊治疗用途要素制剂 □非要素制剂：□混合奶 □匀浆膳 □营养配方：□儿童型 □成人型 ★肠外营养途径：□中心静脉：□经外周静脉中心静脉置管（PICC） □锁骨下静脉 □颈内静脉 □股静脉 □外周静脉 □肠外营养： □单瓶脂肪乳: □长链脂肪乳 □中长链脂肪乳 □结构脂肪乳 □鱼油脂肪乳 □单瓶氨基酸：□平衡型氨基酸 □支链氨基酸 □小儿氨基酸 □卡文 □全合一 主任医师/主任： 上级营养医师： 经管营养医师： 标准营养医嘱单 医嘱日期 医嘱内容 营养医师签字 停用日期 标准营养医嘱单（首页） 性别 年龄 岁 职业 输注途径 身高 cm 标准体重 kg 实体重 kg 体温 ℃ 临床诊断 蛋白质热比 克 % 碳水化合物热比 克 % 脂肪热比 克 % 总能量 kcal/day 总氮量 g/day 氮/能量 1: 总液量 ml/day 钠 克 钾 克 钙 克 镁 克 磷 克 维生素C 克 膳食方案 剂 量 肠外营养配方 剂 量 膳食总量 Kcal % 肠外营养总量 Kcal % 肠内营养预包装产品 肠内营养总量 Kcal % 10%氯化钾 水溶性维生素 脂溶性维生素 谷氨酰胺 精氨酸 纤维素 整蛋白型 短肽型 氨基酸型 中链脂肪酸 营养医师签字： 日期： 年 月 日 标准营养医嘱单（续页） 日期 膳食方案 总量 Kcal % 肠内营养预包装产品 膳食总量 Kcal % 10%氯化钾 水溶性维生素 脂溶性维生素 谷氨酰胺 精氨酸 纤维素 整蛋白型 短肽型 氨基酸型 中链脂肪酸 肠外营养配方 总量 Kcal % 总液体量 （ml） 蛋白质 （克/%） 脂肪 （克/%） 碳水化合物 （克/%） 总热量kcal/总氮量g 钾 （克） 钠 （克） 钙 （克） 24小时尿氮排出量g 营养医师签字 标准营养治疗评价单 项目 参考值 治疗前 治疗后 体重（kg） 体质指数 18.5-23 皮褶厚度（㎜） 男：12.5 女：16.5 上臂围（㎝） 男：27.4 女：25.8 臂肌围 男：24.8 女：21.0 肌酐/身高指数（%） 90-110 血清前白蛋白（mg/dl） 25.0-40.0 血清运铁蛋白（mg/dl） 220-400 纤维连接蛋白（mg/L） 200-280 视黄醇结合蛋白（mg/L） 25-69 维生素C（mg/dl） 0.2-0.4 淋巴细胞总数（×109/L） 2.5-3.0 皮肤超敏反应（mm） ≧5 预后营养指数（%） ≧60% 氮平衡（g/d） 血清铁（μmol/L） 7-29 血清锌（μmol/L） 11.6-23.0 血清铜（μmol/L） 10.9-24.3 血清硒（μmol/L） 0.82-4.20 其他： 预后营养指数（PNI）%=158-16.6(ALB)-0.78(TSF)-0.20(TFN)-5.80(DHST) 广东省医院营养科标准营养病历首页 County economic work conference leadership speech:The main task of the twenty-six session of the six plenary meeting of the county the county economic work conference this time, by the partys eighteen and eighteen Third Plenary Session of the spirit as a guide, carry out and implement the central and provincial economic work conference on rural work conference and the three session of the seven plenary session of the party to expand the spirit of the meeting, the total summary of last year the work, analysis of the current situation, the deployment of this work, further strengthening the development of consensus, to mobilize the whole county county, deepening reform and innovation, to work against poverty, accelerate the transformation of leapfrog, promote scientific development, struggling to write a new harmonious beautiful mountains and show a prosperous civilization to build a new building. The following chapter * *, according to the county Discussion of the views of the Standing Committee, I focus on four aspects of the problem:* * * years, the county to seriously implement the central decision-making arrangements and real, in accordance with the high position, as a typical tree, catch catch up with speed for a breakthrough, five in one overall grasp to raise human resources to promote overall leap, firmly grasp for the project, investment, industry, structural adjustment, Emegumi Mio, promote harmony, agency the county economy presents the social development to catch up, are balanced development, promote the overall, a good momentum of sustained rise.According to Article 11 priority, economic construction full speed. Focusing on the development of this priority service, set up the market idea is constantly refined, can the implementation of major projects, efforts to expand the investment, vigorously develop the non-public economy, to ensure the continuous healthy and rapid development of the county economy, investment in fixed assets investment, industrial added value. Fiscal income, per capita net income of farmers and other major economic indicators maintained two digit growth. According to the 3341 project engineering, proved reserves pre project 4744, * * 4, for central heating in the west, the South Cave Temple landscape Avenue, oil oil road lifting column ten key counties Project smoothly, investment projects to promote the transformation of the pull, supporting further highlights the role; to promote in Honghe oilfield Mton construction, careful implementation of natural fiber cotton industry a reconstruction and expansion of the two phase, Huarun home ceramics, ceramics, Zhengda feed class three, class 44 full load keep the production, operation and sales booming, the cotton industry has become the city after the coal transport and one employment value-added industry; Xiping railway through infiltration through operations, Jing Road opened to traffic vehicles, further highlights the * * traffic hub; Longyuan red fruit trade company successfully introduced, for the first time now * * fruit Direct export; is a production company 300 thousand tons of feed production line, Yurun Group * * broiler breeding district built colonization production, forming a company + farmers model of development, in promoting the transition to farming aquaculture has taken a solid pace; vegetable industry focus management promotion and marketing docking. Rui Jing River area, vegetable mould scale continues to expand, Wang Rui Feng, and other heavy key towns village village layout, sudden breakthrough strong momentum; Yudu Kang family, Wang twenty shop center village construction into the industry, ecological, cultural, tourism and other factors, the tour group construction community management, Set a benchmark for the new rural construction, the construction of new rural county in the two end of the pilot beam to keep the innovation and enhance the momentum.To accelerate the reform and innovation, political construction steadily. The reform and innovation as the core of the heart, coagulation unite together in political construction, to create a good environment for the countys development. Constantly improve the working mechanism, support peoples congresses, governments, CPPCC Standing Committee work, to further improve and perfect the sub division of responsibility, the full implementation of the county led the pack leader catch the township, contact departments, corporate responsibility system; established a comprehensive assessment of the five one approach, the implementation of Rural Township, Department of secretary of the party organization work the honesty and democratic appraisal system, encourage encourage creative work for the Department of Township, village cadres, and constantly improve the performance assessing and Industry Development Linked incentive mechanism, the formation of winds are strong enough, good momentum and seek common development; communication mechanism and establishment of provinces and cities, double units, actively seek the support of docking project, the implementation of funds, with the country, the province, has injected new impetus to realize synchronous well-off. To strengthen the grassroots base,, take the two push an election and direct push elections , complete the general village two committees , earnestly carry out the development of village level financial clean-up, to fully implement the party, government and village affairs, expand the peoples right to know, participation and supervision rights; in-depth implementation of the four on two open the work of law, and constantly improve the base By election procedure, public consultation and accountability mechanism, promote the masses in industry development, community governance, realize self management, public affairs and public welfare undertakings in the development of self service. To promote the reform of key areas of heavy water, and comprehensively promote the city comprehensive law enforcement, business, food and drug supervision system reform, reasonable the adjustment of discipline discipline inspection and supervision, procuratorate organs, quality inspection departments, strengthen the integration of industry and commerce, service functions, improve administrative efficiency; further promote reform into the right system of rural financial reform and development of collective forest, rural development and further enhance the vitality.Focus on financial integration and development of cultural construction, accelerate the pace of fast. Seize the provinces heritage of Chinese civilization, Chuang Chuang District building, Dayun Temple unearthed cultural relics and Buddhist relics Millennium such as opportunity, efforts to promote cultural tourism integration development. Efforts to enhance the level of planning, and employ high quality planning and design units, the county cultural tourism development planning and the overall planning of the cloud temple, reported the provincial culture to enhance the coordination of regulation to promote the leading group approved in the province, the city within the province, forming a west of Dunhuang, East * * consensus, for my county with rich historical and cultural resources to promote the economic structure turn around, The development of the way to find a starting point. And constantly improve the implementation of the system of scenic spots, water conservation and construction of Tian exhibition hall construction, built the South Cave Temple before a square and landscape Avenue, meticulously made jade Kang Jia Wang Cun, twenty shop ecological tourism demonstration village, Wu Huan Martyrs Memorial Hall preparatory work disabilities progress smoothly and, to further improve the system of tourism attractions. Strengthen the protection of cultural relics, the temple unearthed cultural relics protection such as the focus, to carry out a full survey of cultural relics, registration, maintenance and other work, find out the county cultural relics protection and the status quo. Continue to strengthen publicity and promotion, in order to Buddha seselj Millennium now As an opportunity to successfully held the inauguration cum Dayun Temple Buddha relic Lian in deep mining method; mother of Queen Mother of the west culture, held the fifth cross strait Coast West Queen female culture seminar by Chinese intangible cultural heritage center initiative, the West Queens birthday was established as the Chinese mothers day, I determine the county as the international mother queen mother of the west culture the research base in Beijing; the success of the Gansu Buddhist Culture Research Seminar * *, established Chinese and international Fobao Holy Buddha relic research center position, CCTV and Macao and so on a number of media for the depth, resulting in extensive influence at home and abroad, visibility and influence * * * culture brand The sound is further improved.Efforts to improve the peoples livelihood and social construction fruitful. Adhere to the people-oriented, pay more attention to social construction, efforts to improve the peoples livelihood security barrier level. Careful measures do Huimin practical, double, agricultural loans, and poverty alleviation development province in the practical handling of solid and effective, especially Jing Hebei road construction, the implementation of the county the 521 thread road reconstruction project, to solve the problems of the masses along the way group years of difficulties and problems, to speed up the development of the country along along conditions. Promote the overall development of social undertakings, adhere to the priority of education development, construction completion of recruit students * * 4, 13 kindergartens expansion and expansion is completed and put into use, 45 schools of food Hall fully completed, a substantial increase in the number of on-line books over the entrance general; all the full implementation of the rural health service ten full coverage, the county food and drug supervision system for continuous improvement; regarded attaches great importance to the work of family planning, the national population and family planning interests to guide policy system construction demonstration county through the provincial inspection;; multi expansion the coverage of social security, technology, radio and television undertakings developed. Continue to deepen the double action, in accordance with the village is linked industry, household income is linked to help ideas, deepening the not rich first help, together with the well-off society theme of practical activities, to build a market wide wide Base platform, connection with the farmers, new farmers professional cooperative economic organization with 121, capital cooperatives 10, first rich guide staff and poverty benefit object to establish the node mechanism, for rich people to fulfill their social responsibilities, to realize their own value to build a platform for poor farmers to get rich extension expand the ways find the starting point, for all levels of cadres to carry out work. To strengthen social governance, to construct the scientific governance pattern of society as the direction, to the township level and village level social service community management as the focus, product actively adapt to the economic structure, organizational form, the trend of diversified values Tie, and carry out the management of rural three movement, five independent, three cooperation for action and a study of three visits three the main theme of practical activities, promoting social comprehensive governance, in-depth investigation and handling of the spear of contradictions and disputes, to crack down on illegal crime, the social stability and development to optimize the environment.Adhere to the comprehensive combination of governance, improve the level of ecological civilization. Ecological construction mode of innovation, to continue to expand the ecological effect, and strive to build the ecological brand, the construction of ecological civilization step pace significantly accelerated. Forestry development efforts of the increase, to control the key areas of green and heavy key River Basin as the focus, carefully implement the whole basin destroy, surface mountain ecological restoration, forest road facilities and villages Tuen green, complete ecological afforestation, mu, ecological barrier function is growing. The environment restoration by Ti Tianjian to accelerate the pace of construction, small watershed management, the governance and the construction of high standard basic farmland for heavy emphasis, additional land acres, national water Soil conservation ecological civilization County created by the provincial approval; in energy development and pollution of heavy industrial enterprises focus on emission reduction as the focus, pay close attention to the implementation of environmental protection measures, environmental quality improved significantly. The effectiveness of county county village of environmental governance, vigorously implement the five force change three construction and reconstruction to carry out comprehensive renovation, village environment comprehensive improvement of the rural environment, dirty, chaotic, and poor problem in some key areas to be solved.Outstanding pioneer leader, continue to strengthen party building. The main building and development of the theme on the buckle, positive innovation carrier, and strive to build the brand, and the scientific level of Party Construction in a step by step improvement. To strengthen ideological and political construction, organization of Party members and cadres to seriously study and implement the partys general secretary of the Third Plenary Session of the eighteen and Xi Jinping series of important speech, enhance ideological and political quality of cadres and Party members at all levels of ability to lead the development of; extensive China country dream publicity and education, and actively promote the harmony, Ten Star filial piety of mass spiritual civilization creation and evaluation, public citizen morals and socialist core The construction of value system. The whole heart constantly strengthen comprehensively strengthen the building of grassroots organizations, to force five hundred points building integrated joint demonstration project, carefully build the Jing water pioneer brand building, earnestly carry out the exhibition home hand in hand to build well-off dream theme activities, and constantly improve the working mechanism of township town Party committee the base, the grass-roots party construction work was significantly improved;; set up in Germany for the first to have both ability and political integrity, and attention to conduct, advocate hard work, outstanding performance, recognized by the masses selection guide, on the part of the Township Town, the Department team has been adjusted, so that a number of pragmatic style, outstanding performance. The masses of the public That cadres be reused;; the full implementation of village cadres remuneration growth mechanism, hiring 150 student village cadres, selected 54 outstanding young cadres to serve the village, 15 outstanding college-graduate village official in Shandong Weifang square, study tours, stimulate the work of cadres working force. Continuing to strengthen cadre style construction, the full implementation of the central eight regulations and the relevant provisions of province, city to beg, carry out the effectiveness storm actions, streamline meeting documents, reduce public official reception, strictly control three funds charges, and resolutely put an end to waste waste, actively carry out the clean room, clean car and normative appraisal standards commend Other special activities, work style continued to improve. Must strengthen clean government, strict accountability, honest government, political party cadres standards, leading leading cadres a pair of responsibility and the political conversation system, education, system, supervision and punishment as the main content of the punishment and prevention system to establish an effective, long-term mechanism of anti-corruption corruption tends to improve, to accelerate the development of the creation of a good environment.The scientific study situation, is the premise and basis of doing all the work. The thorough analysis of the situation, we feel deeply felt, at present, my county is in advance in the crucial period of reform, the transition across the reversal period, the critical period of accelerated development period, even in the golden period of economic development period, superposition the policy of opportunity, the release period after hair advantage, pressure and hope coexist, opportunities and challenges coexist. Can seize the opportunity, meet the challenge, while avoiding disadvantages, to smooth profits, to complete our duties, given the history, is a major issue to be in-depth thinking of the entire County. We should not only in Gu Qing review summary Wake up the understanding of their own difficulties and problems in the development existence, and clarify the opportunities and challenges in the macro situation, but also in the future in the development of law and to grasp and accurately judge the characteristics of order stage, actively adapt to the change trend, firmly establish the feel, hardship, seize the opportunity to tackle, firm speed up the development of faith, struggling to write beautiful beautiful chapter. The spectrum of a prosperous civilization and harmonious construction of the new policeHow to recognize the hardship, is to ask questions, identify the crux of the self pressure. The ancients said: calamity, died of happiness. Facing the new situation of development, we should not only summarize the experience and results, more important is to find out the questions, recognize the gap. For many years, through the tireless efforts of the whole county my county, the economic and social development has made remarkable achievements, but in accordance with the requirements of the new situation and measure, the total economic output is small, the development, open development level is low, the crux of the problem, some of the problems restricting the development has not been fundamentally solved. One is the depth of the development of industrial agriculture is insufficient. Pass. Through exploration and practice, the team and the county cadres and the masses, and the three leading industry begun to regulate livestock scale, benefit initially apparent. But universally exist imperfect market mechanism problem, is still in the standardization of production, market operation, the initial industrialization stage. The fruit industry to expand the amount of quality and efficiency brand is facing many challenges, because in the affected area of cultivated land constraints, the scale of the surface does not have the advantage, we must strengthen management, improve the efficiency of the efforts in depth development, cultivating cluster composition articles, or in a passive situation in the region will be competitive. The animal husbandry industry still to support the project, large pile planting, Small cell model, the total size of small, large fluctuations in the market, the overall efficiency is not high. The government funded the construction of vegetable industry shed, not fully play the role of the masses of the main problems are still very prominent, narrow coverage, low, benefit. By the industry, due to location, influence, historical factors. The industrial economy is small, benefit benefit low, investment and industrial economy main index only rely on the Red River oilfield, natural fiber cotton industry and other enterprises, industrial short board, short legs in the short term is difficult to be solved. It is the third industry, since ancient times is that the west is * * the gateway to Changan City, known as a drought in Eastern Gansu Wharf reputation, section third has the advantage of industry development potential. In recent years, richly endowed by nature of development practice, although Pingding Xiping railway, high-speed, west east gas pipeline and other projects have been completed, but only just play channel role, role of logistics industry development of the * * * pull action is not obvious, not due to the birth of the logistics industry system, but not very good will * * regional advantages into economic advantage. The two is the construction of urbanization is a heavy task. The county is an important joint to promote the development of county urban-rural integration and leading. In recent years, our development in the county has done a lot of work, but because of by soilfor the national strategy of developing the West, Yibin city as Yangtze towns and Southern towns, have become areas of Sichuan, Yunnan and Guizhou provinces central city location advantages, will take Chengdu, Chengdu, Chongqing, Chongqings County economic work conference leadership speech:The main task of the twenty-six session of the six plenary meeting of the county the county economic work conference this time, by the partys eighteen and eighteen Third Plenary Session of the spirit as a guide, carry out and implement the central and provincial economic work conference on rural work conference and the three session of the seven plenary session of the party to expand the spirit of the meeting, the total summary of last year the work, analysis of the current situation, the deployment of this work, further strengthening the development of consensus, to mobilize the whole county county, deepening reform and innovation, to work against poverty, accelerate the transformation of leapfrog, promote scientific development, struggling to write a new harmonious beautiful mountains and show a prosperous civilization to build a new building. The following chapter * *, according to the county Discussion of the views of the Standing Committee, I focus on four aspects of the problem:* * * years, the county to seriously implement the central decision-making arrangements and real, in accordance with the high position, as a typical tree, catch catch up with speed for a breakthrough, five in one overall grasp to raise human resources to promote overall leap, firmly grasp for the project, investment, industry, structural adjustment, Emegumi Mio, promote harmony, agency the county economy presents the social development to catch up, are balanced development, promote the overall, a good momentum of sustained rise.According to Article 11 priority, economic construction full speed. Focusing on the development of this priority service, set up the market idea is constantly refined, can the implementation of major projects, efforts to expand the investment, vigorously develop the non-public economy, to ensure the continuous healthy and rapid development of the county economy, investment in fixed assets investment, industrial added value. Fiscal income, per capita net income of farmers and other major economic indicators maintained two digit growth. According to the 3341 project engineering, proved reserves pre project 4744, * * 4, for central heating in the west, the South Cave Temple landscape Avenue, oil oil road lifting column ten key counties Project smoothly, investment projects to promote the transformation of the pull, supporting further highlights the role; to promote in Honghe oilfield Mton construction, careful implementation of natural fiber cotton industry a reconstruction and expansion of the two phase, Huarun home ceramics, ceramics, Zhengda feed class three, class 44 full load keep the production, operation and sales booming, the cotton industry has become the city after the coal transport and one employment value-added industry; Xiping railway through infiltration through operations, Jing Road opened to traffic vehicles, further highlights the * * traffic hub; Longyuan red fruit trade company successfully introduced, for the first time now * * fruit Direct export; is a production company 300 thousand tons of feed production line, Yurun Group * * broiler breeding district built colonization production, forming a company + farmers model of development, in promoting the transition to farming aquaculture has taken a solid pace; vegetable industry focus management promotion and marketing docking. Rui Jing River area, vegetable mould scale continues to expand, Wang Rui Feng, and other heavy key towns village village layout, sudden breakthrough strong momentum; Yudu Kang family, Wang twenty shop center village construction into the industry, ecological, cultural, tourism and other factors, the tour group construction community management, Set a benchmark for the new rural construction, the construction of new rural county in the two end of the pilot beam to keep the innovation and enhance the momentum.To accelerate the reform and innovation, political construction steadily. The reform and innovation as the core of the heart, coagulation unite together in political construction, to create a good environment for the countys development. Constantly improve the working mechanism, support peoples congresses, governments, CPPCC Standing Committee work, to further improve and perfect the sub division of responsibility, the full implementation of the county led the pack leader catch the township, contact departments, corporate responsibility system; established a comprehensive assessment of the five one approach, the implementation of Rural Township, Department of secretary of the party organization work the honesty and democratic appraisal system, encourage encourage creative work for the Department of Township, village cadres, and constantly improve the performance assessing and Industry Development Linked incentive mechanism, the formation of winds are strong enough, good momentum and seek common development; communication mechanism and establishment of provinces and cities, double units, actively seek the support of docking project, the implementation of fu