1. Why do you want to learn the core nursing system? 2. What is the most important thing in nursing work? 3. What are you most afraid of when you first enter the clinic? 4. How should you handle your fears? 3 10 core system 1. Medical orders and nursing execution system II. Handover system 3. Check system 4. Nursing rounds system. Nursing consultation system. Critical patient rescue system. Graded nursing system. Reporting and handling system of nursing adverse events. Patient notification system 10. Nursing document writing system. Medical order checking system? Doctor's advice execution system? 1, all kinds of drugs used by patients and all kinds of inspection and operation items should be issued with written doctor's advice and recorded on the doctor's advice record. ? 2, the doctor issued a written doctor's advice, the nurse carefully review the doctor's advice, check, if there is blood coagulation on the doctor's advice should be checked with the doctor who issued the doctor's advice, after confirmation by both parties, copy and print the doctor's advice. 5 doctor's advice execution system? 3, non-emergency cases, doctors may not give oral orders, nurses may not carry out oral orders. For example, during the rescue process, when the doctor gives a verbal order, the nurse should repeat it, only after the doctor agrees, and keep the empty ampoule, and the doctor will supplement the order in time afterwards. 6 doctor's advice execution system? 4. In the weak period at noon or at night, the doctor must remind the nurse on duty to deal with it in time after giving orders. ? 5, the nurse in the process of executing the doctor's advice, found that the doctor's advice has blood coagulation or drug dosage is too large, to check with the doctor who issued the doctor's advice in time and put forward blood coagulation, after confirmed by both parties, can copy and print the doctor's advice. 7 doctor's advice execution system? 6, the main class nurses carefully review and check the doctor's advice, print the doctor's advice label and then check it again by each class. It can only be executed after it is accurate. ? 7, patients with surgery, childbirth, change one's major, discharge or death, the nurse on duty should stop all previous doctor's advice. Second, what are the specific measures to implement the inspection system? (1) Check the doctor's advice? The main shift is responsible for checking all the doctor's orders during the day, the middle shift is responsible for checking the doctor's orders of the class and the day shift, and the head nurse supervises all the long-term and temporary doctor's orders and expenses once a week, and registers and signs them. 9 check the system? (2) check the medication and injection? 1. Three checks and eight pairs must be strictly implemented. Three checks: preoperative check, intraoperative check and postoperative check: bed number, name, drug name, dosage, concentration, time, method and expiration date. 2. Before preparing drugs, check whether the drugs are precipitated, turbid or deteriorated, whether the bottle mouth is loose or cracked, and the validity period and batch number. Do not use it if it does not meet the requirements or the label is unclear. 10 Check the system? 3. After placing the medicine, it must be checked by a second person before implementation. ? 4. Before using allergic drugs, you should ask if you have a history of allergies. When using toxic, hemp and drama-restricted drugs, they should be checked repeatedly, and ampoules should be properly kept after use. When using multiple drugs, we should pay attention to whether there are compatibility taboos. ? 5. When dispensing or injecting, if the patient raises questions, it should be found out in time before implementation. 1 1 Check the system? (3), drug inspection? 1, the classification of drugs in the treatment room is checked by the treatment class. The quality, batch number and expiration date of various drugs are checked once a month and registered and signed, and checked once a week at ordinary times; 12 check the system? 2, special medication by the treatment class custody, registration, check once a week, after use timely supplement; ? 3. The treatment class is responsible for checking the first-aid articles once a week and supplementing the quality, batch number, expiration date and registration signature of the drugs. 13 check the system? (4), intravenous infusion check? 1, strictly check the process. Every day, the number of people in the treatment class and the number of people who deliver the liquid is in the liquid preparation center, and then the treatment class and members of each group (generally two people * * * check together) to check the subjects, liquid name and dosage, and push them to the ward, and check the patient's bed number, name, gender and age again. Please check whether it is correct before performing the operation. 14 check the system? 2. During intravenous infusion, operate in strict accordance with the operating rules of intravenous infusion and fluid addition, and strictly implement the "three checks, eight pairs and one attention" during operation; ? 3, temporary infusion during the day by the main class to print the doctor's advice label to the treatment class, two people * * * check and approved by both sides by the treatment class for liquid preparation, sent to each group of nursing staff. 15 Check the system? (5) Disposable medical supplies shall be collected from the warehouse management personnel by the Japanese nurses every Tuesday, and the validity period, batch number and quality shall be checked. 16 check the system? (6), intravenous blood transfusion examination? 1, after receiving the patient's blood transfusion doctor's advice, the main shift informs each group of nurses to take blood cross samples and send them to the blood transfusion department. After receiving the blood collection notice, they will go to the blood transfusion department to retrieve the blood, and the nurses on duty can enter them after checking them correctly, and double sign them; 17 check the system? 2. Blood transfusion must strictly implement the system of three checks and eight pairs. Three checks: check the validity period of blood, check the quality of blood, and check whether the blood transfusion equipment is in good condition. Eight pairs: name, bed number, medical record number, blood bottle (bag) number, blood type, cross-matching experimental results, blood type and dosage. 18 Check the system? 3. Observe closely during blood transfusion and prepare for rescue. After blood transfusion, blood bottles (bags) should be kept for 24 hours for inspection when necessary. Transfusion within 30 minutes after blood collection, observation for 5- 10 minutes, patients can leave without abnormality; ? 4, night shift emergency blood transfusion by the nurse on duty and the doctor on duty two people * * * double signature before input. 19 Check the system? (seven), each class in the implementation of treatment and nursing operations, must strictly implement the "three check eight pairs, one attention". Third, the grading nursing system? (1) Special care? Nursing content? 1, closely observe the changes of patients' condition and monitor vital signs; ? 2, according to the doctor's advice, the correct implementation of treatment and administration measures; ? 3, according to the doctor's advice, accurately record the discrepancy; 2 1 graded nursing system? 4, according to the patient's condition, the correct implementation of basic nursing and specialist care, such as oral care, ulcer care, airway care and pipeline care. , implement safety measures; ? 5. Maintain the patient's comfortable functional posture; ? 6, the implementation of bedside succession. 22 graded nursing system? (2) Primary health care? Nursing content? 1, patrol patients every hour to observe the changes of patients' condition; ? 2, according to the patient's condition, measuring vital signs; ? 3, according to the doctor's advice, the correct implementation of treatment and administration measures; 23 graded nursing system? 4, according to the patient's condition, the correct implementation of basic nursing and specialist care, such as oral care, ulcer care, airway care and pipeline care. , implement safety measures; ? 5. Provide health guidance related to nursing. 24 graded nursing system? (3) secondary health care? Nursing content? 1, patrol patients every 2 hours to observe the changes of patients' condition; ? 2, according to the patient's condition, measuring vital signs; ? 3, according to the doctor's advice, the correct implementation of treatment and administration measures; 25 graded nursing system? 4, according to the patient's condition, the correct implementation of nursing measures and safety measures; ? 5. Provide health guidance related to nursing. 26 graded nursing system? (4), tertiary care? Nursing content? 1, patrol patients every 3 hours to observe the changes of patients' condition; ? 2, according to the patient's condition, measuring vital signs; ? 3, according to the doctor's advice, the correct implementation of treatment and administration measures; ? 4. Provide health guidance related to nursing. 4. Duty, handover and succession system? (a), the personnel on duty in each class must stick to their posts, perform their duties, and ensure the completion of the diagnosis and treatment, nursing work and nursing records of this class. ? (2). The personnel on duty should do a good job in ward management and strengthen safety management. In case of major problems, please report to your superiors in time. 28 duty, handover and succession system? (3) Before the shift, the attendant must complete the nursing work and record, and tidy up the items. In special circumstances, the shift should be detailed. The dressing change class is responsible for the supplementary work of the items in the dressing room, and the treatment class is responsible for the supplementary work of the items in the treatment room, and make full preparations for each shift. Before the successor is not clear, the successor shall not leave his post, and the problems found in the process of succession shall be raised in person, and the successor shall be responsible. After the succession, the successor should be responsible for the problems caused by unclear handover. 29 duty, handover and succession system? (4), the succession on time, the successor must arrive at the post 15 minutes in advance, do "four look" after the succession, see if there are any doctor's orders to carry out, the succession report, know the patient's position and whereabouts in the ward, see the temperature list of key patients, know if there are any patients with fever to be treated, and see if all the nursing records are complete. 30 duty, handover and succession system? "Five clear" psychotropic drugs quantity and treatment class handover clearly, major surgery, critical, new patients' condition and nursing class handover clearly to the bedside, waiting for the doctor's advice handover clearly to the main class, and all kinds of temporary treatment, intravenous blood transfusion, infusion or special examination patients handover clearly to the treatment class. First-aid equipment, medicines and related items should be handed over to the dressing change class clearly. 3 1 duty, handover and succession system? (5) The team members of each group are responsible for completing all kinds of nursing work and nursing records during the day, so as to achieve the "five checks" to check the initial treatment of new patients, check whether the preparation of surgical patients is perfect, check the skin of critical, severe and paralyzed patients, check whether the patient's excreta is handled properly, and check whether the patients' various catheters are unobstructed. 32 duty, handover and succession system? (6) Morning shift: (1) Every morning at 8: 00, all nurses attend the shift and stand in the nursing room collectively. Participants were full of energy, focused, serious-looking, neatly dressed, well-listed, and shift nurses stood opposite all nurses. 33 duty, handover and succession system? (2) release the manuscript and hand-over, and report the patient's access, critical condition, operation, condition change and special wound, etc. In a concentrated and concise manner. Succession nurses should listen carefully to the contents of the shift, and ask questions if they are not clear. 34 duty, handover and succession system? (3) The head nurse should focus on checking the nurse's dress, pay attention to whether the nurse listens carefully to the contents of the shift and ask questions according to the situation, and comment on the sanitary arrangement of the nurse station and treatment room; At the same time, emphasize the focus of the day's work. The bedside handover will take place immediately after the handover in the nursing room. The head nurse led each group leader and the class 2 staff in charge of each group to carry out bedside shift change, and * * * patrolled patients with critical illness, major surgery and special changes in their condition, focusing on the nurses' service attitude, health education, cleanliness and hygiene, and skin pressure ulcers. 35 Duty, handover and succession system? (4) In the afternoon, the class two staff in each group will hand over the new arrivals, patients with special changes and patients with special treatment to the team leader. ? (5) Night shift handover: shift handover shall be carried out by team leaders and night shift personnel, and bedside shift handover shall be carried out in addition to office handover. * * * The system of duty, handover and succession shall be implemented for patients with critical illness, major surgery, special changes in condition and need to turn over? (7), each group of personnel on duty is responsible for receiving new patients, writing ward handover report, the report requirements are true, clear, concise and coherent, clear ward dynamics, discharge, transfer, new, surgery, critical, and so on and so forth. 37 duty, handover and succession system? (8). The head nurse shall make rounds at least twice a day, once after work in the morning and once before work in the afternoon, and supervise and guide the handover. Focus on the day's nursing work and actual situation, find problems and correct them in time to eliminate and reduce nursing hidden dangers. Make daily rounds before coming off work, explain the special precautions and work during night shift, and ensure the continuity of nursing work. Five, 38 blood transfusion safety management system? (a) blood transfusion safety inspection system? (1) Before blood transfusion, "three checks and eight pairs" must be carried out by two medical staff and signed: ① Check the bed number, name, medical record number, blood bag number, blood type, cross test result, blood type, blood product dosage and expiration date, blood quality and quantity, and blood transfusion package of the recipient together with the medical record; ② Check: barcode, blood type (including. 39 blood transfusion safety management system? (2) During blood transfusion, two medical staff should check the patient's name, medical record number and blood type (including Rh factor) again based on the patient's medical history, cross-matching report and blood bag. After the approval is correct, start infusion. 40 transfusion safety management system? (3) Input within 30 minutes after blood collection, observe for 5- 10 minutes after blood transfusion, and the patient can leave without abnormality. ? (four) blood transfusion should be in accordance with the doctor's advice, strict aseptic operation, with a standard blood transfusion device for blood or blood components. 4 1 transfusion safety management system? (5) Before blood transfusion, gently mix the ingredients in the blood bag to avoid strong shock, and no drugs should be added to the blood. ? (6) When the blood of different blood donors is continuously infused, after the first bag of blood is infused, the pipeline of the blood transfusion device is washed clean with a small amount of sterile physiological saline, and then the next bag of blood is continuously infused. 42 transfusion safety management system? (seven) in the process of blood transfusion should be slow first and then fast, according to the condition and age to adjust the infusion speed, and closely observe whether there is any adverse reaction of blood transfusion. If hemolytic or bacterial transfusion reaction is suspected, stop transfusion immediately. Intravenous injection of normal saline to maintain venous access, timely report to the superior doctor, active treatment and rescue. 43 blood transfusion safety management system? (eight) after blood transfusion, carefully check the puncture site for blood swelling or exudation. Empty blood bags were kept for 24 hours, and cross-matching reports were kept in medical records. ? (9) If there is any adverse reaction to blood transfusion, the reaction shall be recorded and the original bag shall be sent to the blood transfusion department to find out the reason. 44 six. Critical patient rescue system 1. Rescue requirements: ① Maintain a serious, earnest, positive and orderly working attitude and race against time to rescue patients. (2) ideas, organizations, drugs, equipment and technologies to be realized. 2. Rescue medical devices and medicines: they must be in a state of complete emergency and managed according to the principle of "four decisions". 3. What the nurse can do: When the patient is in danger, before the doctor arrives, the nurse should give whatever rescue measures she can according to the condition, such as timely oxygen supply, sputum aspiration, blood pressure measurement, venous access, artificial respiration, heart compression, etc. 45 critically ill patients rescue system 4. Clear division of labor, close cooperation, obey orders, stick to their posts, and strictly abide by rules and regulations and rescue procedures. 5, closely observe the condition changes, on-site rescue, stable rear can move. 6, timely and correctly implement the doctor's advice: repeat the oral doctor's advice, keep ampoules, check the records and discard them, reminding medical students to fill the doctor's advice immediately and truthfully. 46 critically ill patients rescue system 7. Nursing records: ① Detailed, timely and correct records; (2) due to rescue patients did not write in time, should be added within 6 hours after the rescue, and indicate; 8. Contact the patient's family or unit in time; 9. After the rescue, timely replenish the medicines and articles of the rescue vehicles, and make the rescue instruments in emergency standby state; 47. Nursing adverse event reporting and handling system? 1, nursing unit design:? (1) "plan" to prevent nursing adverse events from happening? ② Establish a "registration book" of nursing adverse events, and timely and truthfully register them? 2. After the occurrence of adverse events: (1) timely and truthfully report and actively take rescue or rescue measures to minimize or eliminate adverse consequences. ? ② Relevant records, specimens, test results and related drugs and instruments shall be properly kept, and shall not be altered or destroyed without authorization? (3) Reporting time: immediately —— The client immediately verbally reports to the medical students on duty, the nursing team leader/nurse in charge, and if necessary, reports to the 48 Nursing Adverse Event Reporting and Handling System step by step? On the same day: the head nurse reported to the director of nursing department? Fill in the nursing adverse event report within 24 hours? Submit the investigation and treatment form of nursing adverse events within 7 days. 49 patient notification system? 1, patients have the right to accept and refuse treatment. ? 2. What the nurse told us: the pretreatment process, potential dangers, side effects and expected consequences of various nursing operations and some special treatments. ? 3. Explain in a standardized way and in a language that patients can understand, and try to avoid using technical terms? 4. Informed consent for using nursing technology? No matter what causes the operation to fail, you should apologize politely to get the patient's understanding. 50. Risk factor score of high-risk assessment project of falling/falling off the bed Age: ≥65 years old 1 Fall history: before hospitalization 1 year fall/falling off the bed history 1 visual and auditory balance: visual and auditory abnormality, gait instability, dizziness 2 limbs: limb deformity, hemiplegia, decreased limb muscle strength, need help when moving 3 neurology department: Irritability and coma 3 drug effects: sedation/analgesia/sleeping/diuresis/laxatives/antihypertensive drugs/hypoglycemic drugs 1 others: no escort during hospitalization 1 use of air cushion bed 1 5 1 falling bed/falling bed treatment process? Do a good job in preventive treatment procedures? Take safety precautions, such as falling out of bed → arrive immediately → inform the doctor to check the injury → judge the condition → take first aid measures → strengthen patrol → closely observe the change of the condition → accurately record → handle the falling out of bed for 52 consecutive times? Reporting procedure? When the patient falls off the bed or falls, he should immediately arrive, notify the doctor, check the injury, judge the condition, take first aid measures, fill out the report form of falling off the bed, and report the adverse events to the head nurse, who will report the grading standard of 53 for preventing pressure ulcers step by step according to the situation. Scoring standard:? The score of (1) is 15 ~ 18, indicating mild danger, and comprehensive assessment is conducted every two weeks. ? (2) 13 ~ 14 indicates moderate risk, and the whole area is evaluated once every 1. ? (3) 10 ~ 12 is highly dangerous and should be evaluated once every three days. ? (4) Those who score below 9 points are extremely dangerous, and comprehensive evaluation is conducted once a day. Score > 18 Stop evaluation. Thank you for your support. Let's complete the establishment of the Second Hospital together!