The formation of nursing: 1, early human care-regardless of doctors and wizards; 2. Medieval nursing-the hospital was founded by nuns; 3. Renaissance-becoming an independent aristocratic profession; 4. Religious Reform-dark period; The basic tasks of nursing are: relieving pain, preventing diseases, restoring health and promoting the material environment of healthy hospitals; Space, temperature, humidity, ventilation, light, sound, decoration; Among them, the distance between beds shall not be less than one meter, and curtains shall be provided between beds when necessary. General ward temperature 18 ~ 22, neonatal and elderly ward temperature should be kept at 22 ~ 24. The humidity of the ward should be 50% ~ 60%. Opening the window and ventilating for 30 minutes can achieve the purpose of replacing indoor air. During the day, the ideal noise intensity of the hospital should be kept at 35 ~ 45 decibels. Nurses should do "four lightness" in their work, that is, speak lightly, walk lightly, operate lightly and open and close doors lightly. The operating room should be decorated with green or blue to make patients feel quiet and trust! The interpersonal relationship in the hospital mainly includes: nurse-patient relationship, patient-friend relationship and patient-other personnel relationship. Bed unit refers to the furniture and equipment provided by medical institutions to patients during hospitalization. It is the most basic living unit for patients to rest, sleep, eat, excrete and treat. The method of making the bed includes arranging spare beds, temporary empty beds, anesthesia beds and beds for bedridden patients. During the operation, the bedside table is about 20 cm, and the bedside chair 15 cm is removed. Nursing procedures for inpatients: go through admission procedures, carry out sanitary disposal, and escort patients into wards. Nursing care of general patients after admission: prepare bed units, welcome new patients, measure patients' temperature, pulse, respiration, blood pressure and weight, measure and record their height when necessary, inform doctors to see patients, assist in physical examination or treatment when necessary, and fill in admission cases and related nursing forms (fill in the eyebrow column page by page with blue pen and search various forms of hospitalization cases, and record the first basic life disease and height and weight vertically between temperature sheets, and fill in the admission registration card with red pen. Nursing care of emergency patients after entering the ward: prepare the bed unit, prepare the first-aid articles and medicines, cooperate with the rescue, and temporarily keep the accompanying staff for graded nursing; According to the severity of illness and the different nursing levels of patients' self-care ability, they are divided into four levels, namely, super nursing, first-class nursing, second-class nursing and third-class nursing. Nursing care of special care recipients; The patient is in critical condition and needs to be observed and rescued at any time. (such as organ transplantation after severe trauma, complicated and difficult major surgery, extensive burns and serious medical diseases, etc.). ) the content of nursing; Arrange special personnel for 24-hour nursing, closely observe the changes of illness and vital signs, formulate nursing plans, strictly implement various diagnosis and treatment and nursing measures, fill in special nursing records in time and accurately, prepare medicines and medicines needed for first aid, do basic nursing well, prevent complications and ensure the safety of patients. Primary health care; Applicable object; The patient is critically ill and needs absolute rest. (such as various major operations, shock, coma, paralysis, high fever, massive bleeding, liver and kidney failure and premature infants, etc.). ) nursing content; Patrol patients every 15~30 minutes to observe the changes of illness and vital signs; Make a nursing plan, strictly implement various diagnosis and treatment and nursing measures, and fill in special nursing records timely and accurately; Do a good job in basic nursing, prevent complications and meet the physical and mental needs of patients. Secondary nursing, applicable object; The patient is seriously ill and can't take care of himself (such as those who are in stable condition after major surgery, the elderly, the infirm, the chronically ill and the children, etc.). ); Patrol patients every 1~2 hours to observe their condition; Nursing according to routine nursing: giving necessary life and psychological support to meet patients' physical and mental needs. Three-level nursing, applicable object; The patient's condition is mild and he can basically take care of himself. (such as general chronic diseases, disease recovery period, preoperative preparation stage, etc. Nursing content: patrol the patient twice a day to observe the condition; Nursing according to routine nursing; Give health care guidance, urge patients to abide by hospital rules and regulations, and meet patients' physical and mental needs. Chapter IV Comfort and Safety Comfort; It refers to a self-feeling that an individual is in a state of relaxation, satisfaction, freedom, no anxiety, no pain and health. Uncomfortable; The physical and mental health of an individual is imperfect or defective, and his physical and mental needs cannot be fully met. Pain is the most serious symptom of discomfort. Nursing principles for patients with discomfort; Give priority to prevention and promote the comfort of patients; Strengthen observation and find out the cause of discomfort in time; Take effective measures to eliminate or alleviate discomfort; Trust each other and give psychological support. Lying position; Classification of supine position; Active position, passive position and forced position. Change your posture at least every two hours. Common supine position; Supine position (supine position without pillow ~ anesthetized patient; Patients with concave bedsore ~ shock; Patient supine position ~ abdominal examination and catheterization; ), lateral position (enema, anal examination and gastroscopy, colonoscopy, intramuscular injection, prevention of pressure ulcers), semi-sitting position (patients after face and neck surgery, patients with dyspnea caused by heart and lung diseases, patients with inflammation after thoracoabdominal pelvic surgery, patients with weak constitution during recovery period), sitting position (patients with heart failure, pericardial effusion and bronchial asthma attack), prone position (abdominal pain caused by low back examination or flatulence), head and back. Premature rupture of membranes during pregnancy, traction of calcaneus and tibia tubercle), head high and foot low posture (patients with cervical fracture, prevention of brain edema, anti-traction during skull traction of patients after craniocerebral operation), knee-chest posture (anus, rectum and sigmoidoscopy, correction of fetal malposition or uterine anteversion, and promotion of postpartum uterine recovery). This means that the subjective feeling related to existing or potential tissue damage is the body's defensive response to harmful stimuli. ) The characteristic of pain is 1. Pain is a dangerous warning to individual aggression; 2. Pain is a feeling of physical and mental discomfort; 3. Pain is often accompanied by physiological, behavioral and emotional reactions. Nursing evaluation of pain; Evaluation content; The location, time, nature, degree and manifestation of pain. The World Health Organization divides pain into four grades, namely; Level 0, painless; 1 grade (mild), with pain but not serious, tolerable, and sleep is not affected. Grade 2 (moderate), obvious pain, unbearable sleep disorder, need sedative; Grade 3 (severe), severe pain, unbearable sleep disorder, need painkillers. Nursing measures; Reduce or eliminate the causes of pain, relieve or alleviate pain, and provide a comfortable and safe environment for psychological care; It refers to a safe environment without danger or injury. Common unsafe factors in hospitals; Mechanical injury, temperature injury, chemical injury, biological injury, psychological injury and iatrogenic injury. Common protective devices; Auxiliary devices commonly used for bed rails, restraint belts and support frames; Crutch (user's height minus 40 cm), crutch. The fifth chapter is the concept of preventing and controlling hospital infection; Hospital infection can be divided into broad sense and narrow sense, generally referring to the narrow sense, that is, the infection acquired by inpatients in the hospital, including the infection during hospitalization and the infection after discharge. Classification; Exogenous infection and endogenous infection. Basic conditions for formation; Sources of infection, transmission routes and susceptible hosts. Clean; The purpose of removing dirt, dust and organic matter from the surface of an object by physical methods is to remove and reduce microorganisms, not to kill them. Disinfection; Remove or kill all microorganisms except spores by physical or chemical methods. Sterilization; It means to kill all microorganisms by physical or chemical means. Choose disinfection method according to the nature of disinfection items; 1. High-pressure steam sterilization is the first choice for high-temperature moisture-proof articles; 2. Those who are afraid of heat, humidity and valuables should be sterilized with formaldehyde or ethylene oxide gas. 3. Metal sterilization should use a sterilizer with low corrosiveness. 4. When disinfecting the surface of an object, the surface characteristics should be considered. Glossy surface can be wiped by ultraviolet disinfection or liquid disinfectant, and the multi-empty surface can be wiped by spray disinfection. Aseptic technology; It refers to a series of operation techniques and management methods to keep sterile articles from being polluted and prevent all microorganisms from invading or spreading to others during medical care operation. Sterile articles: articles that have been sterilized by physical or chemical methods and are not contaminated. Sterile area: the area not polluted by chemical disinfection after the shopping ceremony. Non-sterile area: an area that has not been sterilized or contaminated after sterilization. Technical principle of aseptic operation: 1 The environment should be clean and spacious: the environment should be spacious and disinfected regularly, and the work of sweeping the floor and changing sheets should be stopped half an hour before the operation to reduce walking and avoid unnecessary crowd flow and textile dust flying. 2. The staff's clothes meet the requirements of aseptic operation: before aseptic operation, the staff should wear clean clothes, wash their hands and wear masks. Masks should be changed every 4-8 hours. Once wet bacteria are easy to penetrate, they should be replaced in time. 3. Orderly goods management; Sterile items should be placed separately from non-sterile items and clearly marked. Sterile articles should not be exposed to air and should be stored in sterile bags or containers. The item name, sterilization date and expiration date shall be indicated. Sterile bags are valid for seven days, and sterile holding forceps should be used when taking them. Once the sterile items are taken out, they cannot be put back into the sterile container. If it is suspected that the goods are contaminated, they should be replaced and disinfected again. 4. Clear sterile area and non-sterile area; The operator's body should keep a certain distance from the sterile area, and should face the sterile area when taking and placing articles. Don't cross the sterile area with your arm. Don't touch sterile items with your hands. Avoid laughing, coughing, sneezing and unsterilized items touching or passing through the sterile area. 5. A set of sterile articles is used by one employee and one patient to prevent cross infection. Sterile holding forceps; Classification: Oval (non-load-bearing) trident (load-bearing) pliers (small articles) Sterile pliers are soaked in disinfectant 2~3 cm above the joint axis and fixed in the upper third by hand. Sterile articles are generally valid for seven days, but they can only be opened for 24 hours, and the sterile tray is valid for 4 hours. Isolation: it is to prevent the spread of microorganisms by controlling the source of infection, cutting off the route of infection and protecting susceptible people. Classification: infectious disease isolation and protective isolation. Isolation types: strict isolation (cholera, plague), respiratory isolation (tuberculosis, epidemic cerebrospinal meningitis), intestinal isolation (typhoid, dysentery, hepatitis A), contact isolation (tetanus, gas gangrene), blood-body isolation (hepatitis B, AIDS, syphilis), insect isolation (epidemic encephalitis B, epidemic hemorrhagic fever, typhoid scar, typhoid fever). Isolation gown's collar and inner face belong to the clean area. If you tie your hair, soak it in 30% alcohol and comb it carefully! Pot bath is forbidden for more than 7 months of pregnancy. Pressure ulcer: also known as pressure ulcer, refers to the tissue ulceration and necrosis caused by long-term compression of local tissue, blood circulation disorder, persistent ischemia and hypoxia and malnutrition. Mechanical factors of pressure sore; Pressure, shear force and friction force.
Patients who are also stimulated by local dampness and excreta, systemic malnutrition or edema are restricted. Classification and clinical manifestations of pressure ulcers: blood stasis ruddy stage, inflammatory infiltration stage and ulcer stage. Features: 1 degree pressure sore shows dark red skin. Redness, swelling, fever, pain and numbness. Characteristics of second degree trauma; The skin is purplish red, with induration under the skin. The skin becomes thinner due to edema, and there is inflammatory exudation, which forms blisters of different sizes and ruptures to form a flushed and moist wound. Third-degree pressure sore: superficial tissue infection, suppuration, abscess formation after outflow, infection in necrotic ulcer stage spreads to the surrounding and deep, often reaching the bone surface, and the black purulent secretion of necrotic tissue increases, which smells bad! Conditions for effective rest: adequate sleep, comfortable body and relaxed spirit! Skeletal muscle status: Grade 0 complete paralysis.
1 level muscles contract slightly but have no limb movement, and level 2 limbs can move but cannot be lifted. The third limb can be lifted off the bed surface but can't resist the resistance;
Grade 4 can resist resistance exercise, but the muscle strength is weakened; Grade 5 muscle strength is normal; Classification of physical activity ability; 0 degrees can be completely independent and free to move. 1 degree requires the use of equipment or instruments. Second, it needs the care, help and education of others; 3 degrees needs both help and equipment and machinery. 4 degrees is completely independent. Muscle training: Isometric exercise and isotonic vital signs are the general names of body temperature, pulse, respiration and blood pressure. Generation of body temperature: oxidative decomposition of sugar, fat and protein. Regulation of body temperature: autonomic thermoregulation and behavioral thermoregulation. Physiological changes of body temperature: day and night, age, activity, drugs and others (such as environment, diet, mood, etc. ) fever degree: low fever 37.3 ~ 38.0; The medium heat is 38.1~ 39.0; High fever 39. 1~4 1, 0; The process of high fever above 4 1 degree: heating period, high fever duration and fever reduction period: heat leakage (lasting 39~40 degrees) is seen in pneumonia and typhoid fever; Relaxation fever (above 39 degrees, with great fluctuation) is seen in septicemia and rheumatic fever; Intermittent fever (suddenly rising above 39 degrees) is common in malaria: if fever is ignored: nursing care of high fever: cooling (physical cooling such as cold therapy), rest, keeping the diet clean and comfortable, safe nursing, psychological nursing: nursing care: strengthening observation of illness; Health education.