A, grading nursing work system
Critical patient care
Keep a close eye on the changes of the condition and change the shift.
Stabilize the patient's mood, and place the patient in the emergency room, intensive care unit or single ward according to the doctor's advice, with appropriate indoor temperature and humidity.
Prepare to rescue medical equipment, change disinfection materials regularly and be on standby. Once the condition changes, immediately assist the doctor to rescue, and make records and processing materials after the rescue.
Timely and correctly implement the doctor's advice and earnestly implement various treatment measures.
According to the routine implementation of various nursing measures, so as to take medicine to the mouth and ensure the smooth flow of various pipelines.
Write nursing records of critically ill patients as required.
Do a good job in basic care and life care, and keep "six cleanness" (oral cleaning, hair cleaning, skin cleaning, perineum cleaning, bed sheet cleaning and clothes cleaning).
To understand the psychological changes of patients and provide nursing consultation and health education for patients and their families according to the doctor's advice and illness.
First-class nursing
Find the change of illness at any time, correctly implement various treatment and nursing measures according to the doctor's advice and relevant indicators of illness detection, take medicine to the mouth, and fill in various nursing records as required.
Prepare emergency medical equipment according to the doctor's advice.
Prevent various nursing complications.
Do a good job in morning and evening care, and keep the bed unit clean, dry, flat and free of peculiar smell.
Give careful care in life to meet the reasonable requirements of patients.
Provide nursing consultation and health education for patients and their families according to the doctor's advice and illness.
Secondary nursing
(1) Regularly observe the condition, reaction after special treatment or special medication, and make nursing records.
(2) according to the doctor's advice, guide patients to moderate activities.
(3) Correct implementation of doctor's advice and medication.
(4) Give necessary help in life.
(5) according to the doctor's advice and illness, provide nursing consultation and health education for patients and their families.
4, tertiary care
(1) Observe the change of illness and make nursing records.
(2) the correct implementation of medical advice.
(3) to guide the patient's diet and rest.
(4) according to the doctor's advice and illness, provide nursing consultation and health education for patients and their families.
Attachment: graded nursing content
First-class care: ① The patient is in critical condition and needs to stay in bed absolutely.
(2) within seven days after major surgery.
③ All kinds of major operations 1-3 days.
④ Coma, shock, renal failure, convulsion and other patients.
⑤ Life can't take care of itself. One of them met the standard and was included.
Grade II nursing: ① those whose symptoms disappeared in acute stage.
② Patients with stable condition but unable to take care of themselves after major surgery.
③ Elderly, frail or chronically ill patients.
(4) should not be too active.
⑤ Patients with general or mild eclampsia after operation.
Grade III nursing: ① Generally, chronic diseases are mild.
② Prepare patients and normal pregnant women before operation.
③ Patients with various diseases and postoperative recovery period.
4 people who can get out of bed and take care of themselves.
Second, the ward management system
1, the head nurse is responsible for the nursing management of undergraduate course room under the leadership of the director.
2, keep the department clean, quiet, comfortable, safe and beautiful. Smoking is prohibited in the work area.
3, establish and improve the nursing system, job responsibilities and comply with them.
4, nurses must dress according to the requirements of the hospital, and keep clean and tidy, dignified, generous, elegant talk.
5, authorized by the director, the head nurse management department property, regular maintenance and maintenance of equipment, in a standby state; Establish accounts as required to ensure that the accounts are consistent.
6, strict implementation of hospitalization, visiting, work and rest, disinfection and isolation, nurse-patient communication system, to ensure the patient's rest and medical care.
7, hold regular patient holiday symposium, listen to patients' opinions and suggestions on nursing work with an open mind, and constantly improve and improve the quality of nursing work.
8, according to the doctor's advice and condition to carry out various forms of patient health education.
9, nursing work is patient-centered, adjust and simplify the workflow, convenient for patients.
10, to provide patients with convenient measures within their power.
Three, the nurse on duty, succession system
1. Nurses on duty must stick to their posts, earnestly perform their duties, correctly apply nursing procedures, and timely and accurately execute doctor's orders to ensure the completion of nursing work.
2, the nurse on duty must finish the work of this class before the succession. In case of special circumstances such as rescue, you should finish the rescue work together before you can get off work.
3. The handover of the patient's condition must be carried out by the succession nurse at the bedside of the patient.
4, must be carried out in accordance with the requirements of standardized nursing succession.
5, succession nurses should arrive at the ward in advance, ready to take over. In case of unclear illness, treatment, nursing and articles during the shift change, questions should be raised immediately, and the nurses in shift change should be responsible for the problems found during the shift change; The problems found after the shift are the responsibility of the shift nurse.
6, the succession nurse did not arrive at the post, did not take over, the succession nurse shall not leave.
7, ward succession main content
(1) Ward patient profile: the total number of hospitalized patients, including those discharged from hospital, transferred out, died, transferred in, admitted to hospital, delivered, operated, critically ill, rescued, suddenly ill, specially examined, specially treated, and those who need special care under special circumstances.
(2) Individual conditions of patients: general situation, specialty, treatment, nursing, diet, sleep, rest, recovery, exercise, psychology, specimen collection, etc.
(3) Special medical devices: rescue medical devices, poisons, anesthetics, medicines, etc.
(4) illness records.
(5) General items: make statistics according to the specific regulations and requirements of each department.
(6) Work that has not been completed due to special reasons or needs to be completed by the next shift.
(7) Make a good hand-over record and sign the full name.
8. All critically ill patients, general anesthesia and epidural anesthesia patients, coma patients, paralyzed patients, special cases, etc. When changing majors, they should be escorted by doctors or nurses, not by nurses or workers. Use the "Record Sheet of Patients Changing to Major" to carefully record the situation of changing to major, keep it in the medical record, and submit it to the medical record room together with the medical record.
Fourth, the nursing inspection system
1, nursing operation inspection system
(1) Any nursing operation must be "three checks and seven pairs", "three checks": preoperative, intraoperative and postoperative checks, and "seven pairs": bed number, name, drug name, concentration, dosage, method and time.
(2) When in doubt about various surgical methods, administration routes and drug quality. , confirmed before operation.
(3) If signature is required after verification, the full name and execution time shall be signed.
2, the doctor's advice check system
(1) Copy the doctor's advice and check it again. The copy should be signed.
(2) after sorting out the list of medication, injection, treatment and diet, it must be checked by two people before implementation.
(3) Check the doctor's advice 1 time every day, and the head nurse will check the doctor's advice once a week and record it.
(4) The doctor's advice can only be implemented after verification.
(5) the doctor's advice in question must be checked before execution.
(6) All medical orders shall record the execution date, time and full name.
(7) In addition to rescue or operation, oral medical advice is not allowed. It should be repeated before the oral doctor's advice is carried out, and it can only be carried out after being confirmed by the doctor. The used empty ampoule can be kept, and the doctor can fill in the doctor's advice, and the two can be discarded after checking that it conforms to the doctor's advice. All orders that need to be executed in the next shift must be handed over in writing and orally.
(two) the check system of medication, injection, infusion and disposal.
(1) Strictly implement the nursing operation check system.
(2) When preparing drugs, check the quality, label, batch number, expiration date, whether the bottle body is cracked, whether the bottle mouth is loose, and whether there are impurities in the bottle. Do not meet the requirements, shall not be used.
(3) After the medicine is distributed, it can be checked by another person.
(4) Before using allergic drugs, patients should be asked whether they have allergic history. Drugs that need a skin test can only be used if the skin test is negative.
(5) Poisonous, hemp and restricted drugs should be checked repeatedly before use, and empty ampoules should be kept for future reference after use, and records should be made.
(6) When using a variety of drugs, we should think of the incompatibility.
(7) When giving drugs or treating, if patients ask questions, they should check them in time, and then execute them and explain them to the patients.
4, blood transfusion inspection system
(1) Before blood transfusion, two people must check and sign their full names.
(2) Check the validity period of blood (date of blood collection), blood quality (with or without blood clot or hemolysis) and whether the blood transfusion device is in good condition (with or without cracks in the blood bag).
(3) Check whether the blood transfusion report is consistent with the name, blood type, blood bag number and blood volume of the blood donor marked in the blood bag.
(4) Check the patient's bed number, name, hospitalization number, blood type, experimental results of cross matching, blood type and blood consumption.
(5) After blood transfusion, the blood bag should be kept for 24 hours for inspection when necessary.
(6) Once blood products leave the correct storage conditions, there is a danger of bacterial reproduction or functional loss. Therefore, the blood bank should be input as soon as possible after snow removal. (After standing at room temperature15-20min).
5, diet inspection system
(1) Nurses check patients' diet every day and inform patients or their families in time.
(2) After the food delivery staff distributes the diet, the nurse should check whether the type and quantity of the diet of special patients are consistent with the doctor's advice.
(3) The diet sent by the family members of special patients can only be given to patients with the consent of doctors, and the nurses should give supervision.
(4) Fasting patients and nurses should do a good job of succession, and inform patients and their families of the purpose and time of fasting, with fasting signs.
(5) The nurse should give guidance to the patient's diet according to the doctor's advice and illness.
Five, the doctor's advice execution system
1, all kinds of drugs, tests and treatment items used for patients should be prescribed by doctors and included in the "doctor's advice". Copying and sorting out doctor's orders must be accurate and must not be altered.
2. After the doctor gives the doctor's advice, the nurse copies it on various "execution orders" and "treatment orders" respectively, and it can only be executed after being checked by two people before execution; Before execution, the doctor's advice in question should be found out, and oral doctor's advice should not be executed except for rescue.
3, in the rescue or surgery, need medication, verbal orders issued by the doctor, the nurse to repeat it again, the doctor to verify the correct rear can perform. After the rescue, the doctor should fill in the doctor's order immediately, and the nurse should fill in the execution time and sign it according to the facts.
4. To execute the long-term doctor's advice, you need to read the contents of the doctor's advice before execution, and then copy the treatment card (or doctor's advice) separately, and then hand it over to another nurse to check that it meets the requirements of the doctor's advice before execution.
5, after the doctor's advice should be carefully checked, once a day, the head nurse check twice a week and sign it. Nurses should check the doctor's advice in each shift; After taking over, check whether the previous doctor's advice is perfect; Check whether there are any new doctor's orders at any time during duty; The nursing department should check the doctor's advice at any time.
6, need the next nurse to perform temporary orders, to explain in succession, and indicate on the nurse's duty record.
7. Under normal circumstances, nurses are not allowed to give symptomatic treatment to patients without doctor's advice. In case of emergency or special circumstances, when the doctor is temporarily absent for some reason, the nurse can give necessary treatment according to the condition, but after treatment, it is necessary to make records and report to the doctor in time to make up the doctor's advice.
Six, nursing document writing system
1, nursing staff strictly implement the writing standards and requirements of nursing documents.
2, all kinds of record specification items conform to the content and evaluation standard of nursing document writing inspection.
3. The recorded contents are objective, true, accurate, timely and complete.
4, record the project is complete, no typos; The format is correct and there are no omissions. Use Chinese, medical terms and commonly used foreign language abbreviations to be concise and to the point.
5. Writing requires seeking truth from facts, being responsible for patients and providing necessary legal basis.
6. Print a nursing record sheet after it is full of pages, and put it into the medical record folder after review. If there is any writing error after printing, it should be revised according to the requirements of the specification, and the original writing should not be covered or removed by scraping, gluing or painting. The revision should not exceed three pages, otherwise it will be reprinted in time.
7. Nursing records written by nurses without registered practice certificate must be reviewed and signed by nurses with professional qualifications.
8. Nursing records should be sent to the medical record room together with medical records within one week after the patient leaves the hospital.
Seven, the rescue work system
1, all kinds of rescue work should be organized and directed by the department director and the head nurse. Nurses involved in the rescue must go all out, have a clear division of labor, cooperate closely, obey orders, stick to their posts and strictly implement various rules and regulations.
2, rescue equipment and medicines must be complete. Personal custody, location, quantitative storage, replenishment at any time after use.
3, nurses must master the use of undergraduate course room main rescue equipment, instruments, memorize its positioning, use, dosage, usage, etc. Rescue drugs so that they can be on the scene.
4. When the doctor doesn't arrive, the nurse should give oxygen, suck sputum, measure blood pressure, establish venous access, carry out artificial respiration and heart massage, match blood and stop bleeding according to the condition.
5, in the process of rescue to closely observe the condition changes, for critically ill patients should be on-site rescue, until the condition is stable rear can move.
6, timely and correct implementation of the doctor's advice, the doctor issued oral orders, the nurse should repeat it. After the rescue, the nurse should remind the doctor to fill in the doctor's orders truthfully.
7. Nurses should make nursing records timely and correctly as required.
8, after the rescue in a timely manner to do a good job of drug replenishment and equipment disinfection.
Attachment: large, medium and small rescue:
ⅰ, big rescue, set up a special rescue team by the hospital, the competent doctors and nurses are not allowed to leave the scene, closely observe the condition changes, such as rescue involves more than two family members, should promptly notify the relevant departments to participate in the consultation, and participate in the rescue.
ⅱ. During the rescue, the department should set up a special rescue team, and the doctors and nurses on duty should not leave the scene to closely observe the changes of the condition. If the rescue involves more than two departments, it shall promptly notify the relevant department personnel to participate in the consultation.
Ⅲ. In minor rescue, the nurse should cooperate with the doctor on duty to rescue the patient on the spot, and closely observe the changes of the condition. If the rescue involves more than two departments, it shall promptly notify the relevant departments to attend the consultation and participate in the rescue.
Eight, emergency medical equipment management system
1. The first-aid drugs and equipment necessary for rescue vehicles in each department must be audited by the department director to determine the type, quantity, specification and dosage.
2. The drug label on the rescue vehicle is clear, and there is no damage, deterioration or expiration; Ensure that the equipment is on standby and timely: timely inspection and maintenance, timely reimbursement.
3. Establish a check card for the emergency medical equipment on the rescue vehicle, indicating that the names, specifications, dosage, quantity and contents of all emergency medical equipment must be completely consistent, and at the same time, establish a registration book for the handover of emergency medical equipment, count the handover by classification, register it correctly, and sign the full name.
4, rescue vehicles must be placed in a fixed point, personnel management, regular inspection and maintenance, ward nurses should be known to everyone.
5. Ensure the effective management of emergency drugs.
(1) When the nurse receives the first-aid medicine, she should give it to the doctor and count it clearly. Nurses have the right to receive drugs with unclear name, expiration date, dosage, unclear label or expired or deteriorated drugs.
⑵ All first-aid drugs that are not equipped with the original medicine box or whose batch numbers are unclear shall be issued by the pharmacy department, with relevant instructions stamped by the pharmacy department and signed by Yamatonokusushi, so as to ensure the safety of patients' medication.
(3) The label of the outer packaging box for storing first-aid drugs should be complete and clear, and the name, specification and dosage of the drugs should be consistent with the outer packaging. If the validity period is inconsistent, it should be indicated on the medicine box for verification. Dose and drug name are inconsistent, and they are not allowed to be placed in the same medicine box.
(4) When the expiry dates of medicines in the medicine cabinet are inconsistent, they shall be stored in the medicine cabinet in the order of expiry dates from left to right, and taken in the order of expiry dates from left to right when in use.
5] First-aid drugs should be replenished at any time after use. If it can't be supplemented due to special reasons such as drug shortage in pharmacy department, it should be noted in the handover register and reported to the head nurse for coordination to ensure the patient's rescue. Used equipment should be replenished, disinfected and sterilized at any time.
The first-class nursing quality control team regularly checks the emergency medical equipment of each department.
Nine, drugs, equipment management system
Drug management system
1, the medicines in the medicine cabinets in each ward shall be kept in a certain number base according to the diseases, which is convenient for clinical emergency use, and the staff shall not take them without authorization.
2, according to the types and properties of drugs (such as injection, oral, external use, highly toxic drugs, etc.). ), respectively located for storage (toxic drugs are kept and used according to the management and use of toxic drugs), with clear labels, daily inspection to ensure their application at any time, and a special person is responsible for receiving and keeping them.
3, regular inventory, inspection of drugs, to prevent the backlog, deterioration, found precipitation, pollution, discoloration, expired, bottle label does not match with the drugs in the bottle, label fuzzy or altered, shall not be used.
4, all rescue drugs, must be set in the rescue car, daily succession, number, location storage, ensure the application at any time, at any time after use.
5, the patient's personal drugs, should indicate the bed number and name, stored separately, after stopping drug timely return to the pharmacy, to avoid waste.
2. Equipment management system
Medical instruments are kept by the responsible nurse, checked regularly, kept in good performance, and carefully handed over in each shift.
Users of medical devices must understand their performance and maintenance methods, strictly abide by operating procedures, clean them after use, and put them back after disinfection.
Valuable instruments must be kept by special personnel and kept clean and dry at all times. After use, the administrator must check whether their performance is in good condition. Various instruments should be properly kept according to their different properties.
Ten, medical malpractice (nursing negligence, defects) registration, reporting and handling system.
1. Each department shall establish a register of errors and accidents, and timely register the time, process, causes and consequences.
2, after the accident, should be based on the principle of patient first, quickly take remedial measures to avoid or reduce the damage to the patient's health or damage to the minimum, in order to reduce or eliminate the adverse consequences.
3, the parties should immediately report to the doctor on duty, the head nurse, the head nurse immediately report to the director, nursing department, nursing department immediately report to the vice president in charge, medical department. And fill in the nursing error registration form according to the regulations and report it to the nursing department.
4. All kinds of relevant records, inspection reports, drugs and instruments that caused the accident shall be properly kept, and shall not be altered or destroyed without authorization for identification.
5, after the accident, the head nurse should organize undergraduate course room nurses to discuss as soon as possible, in order to raise awareness, learn lessons, improve the work, and determine the nature of errors and accidents, put forward handling opinions, and submit written materials to the nursing department.
6. The departments or individuals that make mistakes or accidents will be dealt with according to the relevant regulations of the hospital if they don't report in accordance with the regulations and intentionally hide them, and if they are discovered by leaders or others.
7, nursing department regularly organize relevant personnel to analyze the causes of errors and accidents, put forward preventive measures, and constantly improve nursing management.
8. Handling: according to the severity of the error, oral criticism, written review, economic handling, suspension of reflection, waiting for posts, etc. Will be given separately.
XI。 Disinfection isolation system
Medical staff should wear clean clothes when they go to work and take off their work clothes when they leave the workplace. It is forbidden to wear work clothes to enter non-working places such as canteens, conference rooms and nurseries.
Hand washing or hand disinfection should be done before and after treatment and dressing change.
Sterile containers, instruments, dressing cans, holding forceps, etc. Disinfection and sterilization should be carried out regularly, disinfectant should be replaced regularly, and thermometer should be disinfected by one person.
The ward should be ventilated regularly and disinfected when necessary. The ground should be wet-cleaned, and it should be disinfected immediately if it is polluted. Bedside table, bedside table, chair, door handle, etc. , should be wet every day, rags should be dedicated, thoroughly disinfected after use. Conduct regular air microbial detection. If ultraviolet disinfection is used, it is necessary to register the disinfection time and regularly detect the ultraviolet intensity.
Put the dirty clothes in the designated place, and don't throw them about. It is forbidden to count them in the ward corridor. All kinds of medical devices must be strictly disinfected before they can be used. Medicine cups, tableware and urinals must be disinfected before use. The patient's bedding should be changed and disinfected regularly.
Surgical patients with severe infection and organ transplant patients should be placed separately.
After the patient leaves the hospital, changes his major or dies, he must do a good job in terminal disinfection of the bed unit and wipe the bed, chair, table and wall with disinfectant. Mattress and bedding are washed and disinfected or disinfected by bed unit sterilizer.
Patients with anaerobic bacteria, Pseudomonas aeruginosa and other special infections should be strictly isolated. After use, instruments, clothes and rooms should be strictly disinfected, and used dressings should be burned.
Patients with infectious diseases and their use should be treated according to the disinfection and isolation system of infectious diseases.
Sterile articles shall be inspected once a day, and sterilized articles (cotton balls, gauze, etc.) shall be inspected once a day. ) opened in a sterile storage box, the longest use time shall not exceed 24 hours; Try to use small packages. Used items are strictly separated from unused items and clearly labeled. It is forbidden to use expired items.
Medical staff in workplaces such as outpatient wards should be cleaned and disinfected before coming off work.
Disposable medical supplies and discarded articles shall be disposed of in accordance with regulations, sealed and transported in special containers for harmless treatment.
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