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["　（別紙様式16）　"]
[{"$nulls":21},"訪問看護指示書"]
[{"$nulls":21},"在宅患者訪問点滴注射指示書"]
["※該当する指示書を○で囲むこと"]
[{"$nulls":31},"訪問看護指示期間",{"$nulls":12},"（","　　　　年　　月　　日",{"$nulls":10},"～",null,"　　　　年　　月　　日",{"$nulls":10},"）"]
[{"$nulls":31},"点滴注射指示期間",{"$nulls":12},"（","　　　　年　　月　　日",{"$nulls":10},"～",null,"　　　　年　　月　　日",{"$nulls":10},"）"]
[]
["患者氏名",{"$nulls":30},"生年月日"]
[]
["患者住所",{"$nulls":47},"電話"]
[]
[]
["主たる傷病名",{"$nulls":12},"①",{"$nulls":18},"②",{"$nulls":18},"③"]
["現在の状況（該当項目に○等）",null,null,"病状・治療\n状態"]
[]
[]
[{"$nulls":3},"投与中の薬\n剤の用量・\n用法",{"$nulls":9},"１．",{"$nulls":27},"２．"]
[{"$nulls":13},"３．",{"$nulls":27},"４．"]
[{"$nulls":13},"５．",{"$nulls":27},"６．"]
[{"$nulls":3},"日常生活\n自立度",{"$nulls":9},"寝たきり度"]
[{"$nulls":13},"認知症の状況"]
[{"$nulls":3},"要介護認定の状況",{"$nulls":17},"　要支援　　要介護　（　　　　　　　　　　　　　　　　　　　）"]
[{"$nulls":3},"褥瘡の深さ",{"$nulls":17},"　NPUAP分類（★）　　　　　　　　　　　　　　DESIGN分類（☆）　　　"]
[{"$nulls":3},"装着・使用\n医療機器等",{"$nulls":9},"１．",null,"自動腹膜灌流装置",{"$nulls":16},"２．",null,"透析液供給装置",{"$nulls":16},"３．",null,"酸素療法",{"$nulls":5},"（",{"$nulls":3},"ℓ/min）"]
[{"$nulls":13},"４．",null,"吸引器",{"$nulls":16},"５．",null,"中心静脈栄養",{"$nulls":16},"６．",null,"輸液ポンプ"]
[{"$nulls":13},"７．",null,"経管栄養",{"$nulls":6},"（　経鼻　・　胃瘻　：　サイズ",{"$nulls":26},",",{"$nulls":9},"日に1回交換）"]
[{"$nulls":13},"８．",null,"留置カテーテル",{"$nulls":10},"（サイズ",{"$nulls":15},",",{"$nulls":9},"日に1回交換）"]
[{"$nulls":13},"９．",null,"人工呼吸器",{"$nulls":8},"（陽圧式・陰圧式：設定",{"$nulls":43},"）"]
[{"$nulls":13},"10.",null,"気管カニューレ（サイズ",{"$nulls":22},"）",null,null,"11.",null,"ドレーン（部位：",{"$nulls":24},"）"]
[{"$nulls":13},"12.",null,"人工肛門",{"$nulls":16},"13.",null,"人工膀胱",{"$nulls":16},"14.",null,"その他（",{"$nulls":14},"）"]
["留意事項及び指示事項"]
["Ⅰ　",null,null,"療養生活指導上の留意事項"]
[]
[]
["Ⅱ　",null,null,"１．リハビリテーション"]
[]
[{"$nulls":3},"２．褥瘡の処置等"]
[]
[{"$nulls":3},"３．装着・使用医療機器等の操作援助・管理"]
[]
[{"$nulls":3},"４．その他"]
[]
["在宅患者訪問点滴注射に関する指示（投与薬剤・投与量・投与方法等)"]
[]
["緊急時の連絡先"]
["不在時の対応法"]
["特記すべき留意事項",{"$nulls":11},"（注：薬の相互作用・副作用についての留意点、薬物アレルギーの既往等があれば記載して下さい。）"]
[]
["他の訪問看護ステーションへの指示"]
["  　   無 　有  ："]
[]
[null,"上記のとおり、指示いたします。"]
[{"$nulls":52},"年　　月　　日"]
[]
[{"$nulls":38},"医療機関名"]
[{"$nulls":38},"住所"]
[{"$nulls":38},"電話"]
[{"$nulls":38},"（FAX）"]
[{"$nulls":38},"医師氏名",{"$nulls":27},"印"]
[]
[]
[" 　　済生会まほろば訪問看護ステーション",{"$nulls":25},"殿"]
[]
["★褥瘡の深さの分類　NPUAP（ステージⅢ）：全組織欠損。皮下脂肪は確認できるが、骨、腱、筋肉は露出していないことがある。"]
["★褥瘡の深さの分類　NPUAP（ステージⅣ）：骨、腱、筋肉の露出を伴う全組織欠損。"]
["☆褥瘡の深さの分類　D3：皮下組織までの損傷　　D4：皮下組織を超える損傷　　D5：関節腔、体腔に至る損傷または、深さ判定が不能の場合"]