A hierarchical nursing work system
Critical patient care
Closely observe the changes in the condition, and shift handover.
Stabilize the patient's mood, and according to medical advice to place the patient in the resuscitation room, guardianship room or single room, indoor temperature and humidity is appropriate.
Prepare medicine and equipment for resuscitation, and regularly replace and sterilize the items used, and present them in a standby state, and immediately assist the physician in resuscitation in case of any change in the condition of the patient, and make a good record of the post-resuscitation period and the disposal of the items.
Timely and correct implementation of medical advice, conscientious implementation of various therapeutic measures.
According to the routine implementation of the nursing measures, to achieve the medication to the mouth, to ensure that a variety of pipeline smooth.
Writing nursing records for critically ill patients as required.
Do a good job in basic nursing and life care, keep "six clean" (clean mouth, clean hair, clean skin, clean perineum, clean sheets, clean clothes)
Understand the patient's heart changes, according to the medical advice and the condition of the patient and his family to provide nursing advice and health education.
The first level of nursing care
To find out the change of condition at any time, according to the doctor's advice and condition of the detection of relevant indicators, the correct implementation of the treatment and nursing measures, to do the medication to the mouth, and carefully fill in the requirements of the nursing records.
Prepare the emergency equipment according to the doctor's instructions.
Preventing various nursing complications.
Do a good job of morning and evening care, keep the bed unit clean, dry, flat, no odor.
Living to give thorough care, to meet the reasonable requirements of the patient.
Provide nursing counseling and health education to patients and their families according to medical advice and condition.
Second level care
(1) Regularly observe the condition, the reaction after special treatment or special medication, and make nursing records.
(2) According to the medical advice and guidance to the patient moderate activity.
(3) Correctly carry out medical orders and issue medication to the hand.
(4) Give necessary assistance in living.
(5) Provide nursing counseling and health education to the patient and family according to medical advice and condition.
4, tertiary care
(1) pay attention to the observation of changes in the condition, make nursing records.
(2) Correctly implement the medical advice.
(3) Instruct the patient's diet and rest.
(4) Provide nursing counseling and health education to patients and their families according to medical advice and condition.
Attached: graded nursing content
I nursing: ① critical condition requires absolute bedridden
② within seven days of major surgery
③ within 1-3 days of a variety of major surgery
④ coma, shock, renal failure, convulsions, and other patients
⑤ can not take care of their own life. One of them meets the criteria are included
II level of care: ① serious illness acute symptoms disappeared
② major surgery after the stabilization of the condition but can not take care of their own life
③ old and frail or chronic patients
④ should not be too much activity
⑤ general post-surgery or mild eclampsia patients
III level of care: ① general chronic diseases Mildly ill
② preoperative preparation patients and normal pregnant women
③ various diseases and postoperative recovery patients
④ can get out of bed and activities to take care of their own life
Second, the ward management system
1, under the leadership of the director of the department, the head nurse is responsible for the management of the nursing care of the department.
2, to maintain the cleanliness of the department, quiet, comfortable, safe and beautiful. Smoking is prohibited in the work area.
3, the establishment of a sound nursing system, job responsibilities and follow the implementation.
4, nurses must be uniformly dressed in accordance with the requirements of the hospital, and keep the instrument neat, dignified, generous demeanor, elegant speech.
5, the director of the department authorized, the head nurse of the department's property management, regular maintenance of equipment, maintenance, in a state of readiness; according to the requirements of the establishment of the accounts, and to ensure that the accounts match.
6, the strict implementation of hospitalization, visits, work and rest, disinfection and isolation, nurse-patient communication system to ensure that the patient's rest and the normal progress of medical care.
7, regularly convene the patient's work and rest symposium, listening to the patient's opinions and suggestions on nursing, and constantly improve and enhance the quality of care.
8, according to the doctor's orders and the condition of the patient to carry out a variety of forms of health education.
9, the nursing work to the patient-centered, adjust, simplify the workflow, convenient for patients.
10, for the patient to provide convenient measures within their reach.
Three nurses on duty, shift handover system
1, duty nurses must adhere to their workstations, conscientiously perform their duties, the correct application of nursing procedures, timely and accurate implementation of medical advice to ensure that the completion of the nursing work.
2, the nurse on duty must complete the work of the shift before handing over. In case of rescue and other special circumstances, should *** with the completion of rescue work before leaving work.
3, the handover of the patient's condition must be the handover nurse **** with the patient at the bedside.
4, must be in accordance with the standardized nursing requirements for shift handover.
5, the shift nurse should arrive at the ward in advance, ready to take over. If the condition, treatment, nursing care and goods are not clear during the shift handover, the nurse should immediately check and ask.
6, the shift nurse is not allowed to leave the post before the shift change nurse arrives at the post, and the shift change nurse is not allowed to leave the post before the shift change.
7, the main content of the ward handover
(1) the general situation of the patients in the ward: the total number of inpatients, hospitalization, discharge, transfer, death, transfer, hospitalization, delivery, surgery, critical, rescue, sudden changes in condition, special tests, special treatment patients and patients with special conditions requiring special care.
(2) Individual status of the patient: general condition, specialty, treatment, care, diet, sleep, rest, recovery, exercise, psychology, specimen retention and collection.
(3) Special medicines and instruments: rescue medicines and instruments, poison, anesthesia, limited and dramatic medicines.
(4) Condition records.
(5) General items: inventory according to the specific regulations and requirements of each department.
(6) Work not completed for special reasons or to be completed on the next shift.
(7) Make a record of shift handover and sign full name.
8, all critical patients, general anesthesia and epidural anesthesia, coma, paralysis, special cases and other patients, the transfer should be escorted by doctors or nurses, not to escort or workers on behalf of the transfer, and the use of the "transfer of the patient record sheet" to do a good job of transferring the record, will be saved in the medical record, along with the medical records submitted to the medical records room.
Four, nursing checking system
1, nursing operation checking system
(1) any nursing operation must be "three checking and seven pairs", "three checking": before the operation, operation, operation check, "seven pairs": before the operation, operation, operation check, "three checking": before the operation, operation, operation check, "three checking": before the operation, operation, operation check. "Seven pairs": bed number, name, drug name, concentration, dose, method, time.
(2) When in doubt about the various operating methods, routes of administration, drug quality, etc., the operation must be confirmed to be correct before proceeding.
(3) When signing after checking, you must sign your full name and the time of execution.
2, doctor's orders checking system
(1) the transcription of medical advice should be checked once, the transcriber's signature.
(2) After organizing the medication, injection, treatment and dietary orders, they shall be checked by two persons before execution.
(3) All medical orders are checked once a day, and the head nurse organizes a general check of medical orders once a week and records it.
(4) Medical advice is checked and verified before it is executed.
(5) The medical advice in doubt must be checked and clarified before execution.
(6) All medical advice must record the date and time of execution and sign the full name.
(7) In addition to the rescue or surgical procedures, the implementation of verbal medical advice is not allowed. Before the implementation of verbal medical advice should be repeated once by the physician to confirm that there is no error before the implementation, and to retain the used empty ampoules, to be supplemented by the physician to open the medical advice by the two check with the medical advice in line with the discarded. Any medical advice that needs to be carried out in the next shift should be written and verbalized.
(2) medication, injection, infusion, disposal checking system
(1) strict implementation of the nursing operation checking system
(2) preparation of medicines to check the quality of drugs, labels, batch number, expiration date, bottles of drugs, cracks, bottles of looseness, and bottles of impurities, such as does not meet the requirements, shall not be used.
(3) After setting up the medicine, it needs to be checked by another person for accuracy before execution.
(4) easily sensitized drugs should be asked whether the patient has a history of allergy before administration. Need to do skin test drugs, skin test negative before use.
(5) poison, anesthesia, restriction of drugs should be repeatedly checked before use, and after use to retain the empty ampoule for checking, and make a record.
(6) the use of a variety of drugs, to the idea of contraindications.
(7) When administering or treating medications, if the patient raises questions, they should be checked in a timely manner, and no errors should be made before performing and explaining clearly to the patient.
4. Blood transfusion checking system
(1) Before blood transfusion, two people should check and sign the full name.
(2) Check the expiration date of the blood (date of blood collection), the quality of the blood (whether there is a blood clot or hemolysis), whether the transfusion device is intact (whether there is a crack in the blood bag).
(3) Check whether the transfusion report form matches the blood bag label with the donor's name, blood type, blood bag number, and blood volume.
(4) Check the patient's bed number, name, hospitalization number, blood type and results of cross-matching experiments, type of blood, and amount of blood used.
(5) After the transfusion is completed, the blood bag must be retained for 24 hours for testing if necessary.
(6) Blood products are at risk of bacterial colonization or loss of function once they are removed from proper storage conditions; therefore, they are imported as soon as possible after the blood bank presents the snow, as required. (After 15-20 minutes at room temperature).
5. Diet checking system
(1) Nurses check the type of diet of medically prescribed patients every day and inform patients or their families in time.
(2) After distributing the diet by the delivery person, the nurse should check whether the type and quantity of the special patient's diet is consistent with the medical prescription.
(3) The diet sent by the family of the special patient must be approved by the physician before it is given to the patient, and the nurse should give supervision.
(4) Fasting patients, the nurse should do a good job of shift, and tell the patient and his family the purpose and time of fasting, with fasting signs.
(5) The nurse should give guidance to the patient's diet according to the medical advice and condition.
Fifth, the implementation of the system of medical advice
1, for all kinds of medicines, all kinds of tests, treatment programs should be issued medical advice, and counted in the "medical advice", transcription and organization of the medical advice must be accurate, and shall not be altered.
2, the physician issued a doctor's orders, nurses were transcribed in a variety of "implementation of the single" and "treatment" on the single, the implementation must be double-checked before the implementation of the error; on the question of the medical advice, should be clarified before the implementation of the rescue, in addition to the implementation of verbal The first thing you need to do is to check the medical advice.
3, in the rescue or surgery, the need for medication, the physician issued a verbal medical advice, the nurse recited once, the physician to verify that there is no error before execution. After the end of the rescue, the physician should immediately make up the medical advice, the nurse should accordingly make up the time of implementation and signature.
4, the implementation of long-term medical advice, to do: read the contents of the medical advice before implementation, and then copy the treatment card (or single), handing over to another nurse to verify compliance with the requirements of the medical advice can be implemented.
5, after the implementation of medical advice should be carefully checked, check once a day, twice a week, the head nurse check and sign. Nurses should check the doctor's orders every shift; after taking over the shift should be verified whether the last class of doctor's orders to deal with the perfect; on duty at any time to see whether there is a new doctor's orders; the nursing department of the doctor's orders at any time to spot check.
6, the need for the next shift of nurses to implement the temporary medical advice, the shift handover should be explained, and in the nurse duty record marked.
7, in general, without medical advice, the nurse shall not do symptomatic treatment of the patient, such as emergency or special circumstances, the physician is temporarily absent for some reason, the nurse may be necessary for the condition of the treatment, but the treatment of a good record, and promptly report to the physician to make up for the doctor's orders.
VI. Nursing document writing system
1, nursing staff strictly implement the "Nursing Document Writing Standards and Requirements".
2, a variety of record specification items in line with the nursing paperwork inspection content and evaluation standards.
3, the record content is objective, true, accurate, timely and complete.
4, record items are complete, no typos; correct format, no omissions. Use of Chinese, medical terminology and common foreign abbreviations, simple and concise.
5, writing requirements for factual, responsible for the patient, to provide the necessary legal basis.
6, nursing record sheet full page, in order to review the error-free printing a copy into the medical record folder. Printed if there is a writing error in accordance with the specifications for modification, shall not be used to scrape, paste, paint and other methods to cover up or get rid of the original handwriting. The number of revisions per page is not more than three, otherwise it will be reprinted in a timely manner.
7. Nursing records written by nurses without a certificate of registration must be reviewed and signed by nurses with a license to practice.
8, nursing record sheets should be sent to the case room together with the medical record within one week after the patient is discharged.
Seven, rescue work system
1, all kinds of rescue work should be organized and directed by the department head, head nurse is responsible for the organization, nurses participating in the rescue must go all out, clear division of labor, close cooperation, follow the instructions, and stand firm, and the strict implementation of the rules and regulations.
2, rescue equipment and drugs must be complete. Fixed person custody, positioning placed, quantitative storage, after use at any time to replenish.
3, the nurse must master the main room rescue equipment, instrument use, memorize the rescue drug positioning, use, dosage, usage, etc., to achieve the scene does not mess.
4, the physician has not yet arrived, the nurse should be based on the condition of timely oxygen, sputum, blood pressure, the establishment of intravenous access, artificial respiration and cardiac massage, blood distribution, hemostasis, etc..
5, the rescue process to closely observe the changes in the condition of the critically ill patients should be local rescue to be stabilized before moving.
6, timely and correct implementation of medical advice, the physician issued a verbal medical advice, the nurse should be recited once. After the end of resuscitation, the nurse should remind the physician to make up the doctor's orders according to the facts.
7, the nurse should be in accordance with the requirements of timely and correct nursing records.
8, after the end of the resuscitation in a timely manner to do a good job of replenishing the drugs and instruments, the use of disinfection.
Attachment: the big, medium and small rescue to go:
ⅰ, the big rescue, the hospital set up a special rescue team, the doctor in charge, the nurse shall not leave the scene, closely observe the changes in the condition, such as rescue involves more than two departments, should be informed of the relevant departments in time to the scene of the consultation, and participate in the resuscitation.
II, in the middle of the resuscitation, the department set up a special resuscitation team, the doctor on duty, the nurse shall not leave the scene, closely observe the changes in the condition, such as resuscitation involves more than two departments, should be timely notification of the relevant departments to the scene of consultation.
III, small resuscitation, the nurse with the on-duty doctor on-site resuscitation of the patient, closely observe the changes in the condition, such as resuscitation involves more than two departments, should be timely notification of the relevant departments to the scene of the consultation, and participate in the resuscitation.
VIII. Emergency medicine and equipment management system
1. The emergency medicine and equipment of each department shall be reviewed and approved by the director of the department to determine the types, quantities, specifications and dosages.
2, the rescue car drug labeling is clear, no damage, deterioration, expiration; equipment to ensure that in a state of reserve, to do two timely: timely inspection and maintenance, timely reimbursement claim.
3, the rescue car emergency medicine requires a card, labeling all emergency medicine name, specifications, dosage, quantity, the card must be completely consistent with the goods, and at the same time, the establishment of emergency medicine handover register, shift inventory, handover, registration, no errors and omissions, sign the full name.
4, the rescue car must be placed at a fixed point, fixed management, regular inspection and maintenance, ward nurses should be known to everyone.
5, to ensure the effective management of emergency drugs
1) nurses receive emergency drugs, should be handed over to the physician, check clearly, for the name, expiration date, dosage, etc., unclear, labeling, or expired, deterioration of drugs, nurses have the right to according to the collar.
(2) All emergency medicines that are not equipped with original boxes or with unclear batch numbers should be issued by the pharmacy department with the seal of the pharmacy department and the signature of the pharmacist, in order to ensure the safety of patients' medication.
(3) The labeling of the outer box in which the emergency medicines are stored should be complete and clear, and the names, specifications, and dosages of the medicines should be consistent with the outer package; if the expiration dates are inconsistent, they should be marked in the box for verification; if the dosages and the names of the medicines are inconsistent, they are not allowed to be placed in the same box.
(4) when the expiration date of the drugs in the box is inconsistent, the expiration date is stored in the box in the order from left to right, the use of the expiration date according to the order from left to right to take.
(5) Emergency medicines should be replenished at any time after use, and when they can not be replenished due to special reasons such as lack of medicines in the pharmacy department, they should be noted in the handover register and reported to the head nurse to coordinate and solve the problem, so as to ensure that medicines are used for the patients in the resuscitation. Equipment should be replenished, disinfected and sterilized at any time after use.
Level nursing quality control team to each department emergency medicine equipment regular inspection.
Nine, drugs, equipment management system
A drug management system
1, the ward medicine cabinet drugs, according to the type of disease to save a certain number of base, to facilitate the use of clinical emergencies, the staff shall not be taken without authorization.
2, according to the type and nature of drugs (such as injections, internal, external, poisonous drugs, etc.) were positioned to store (poisonous drugs in accordance with the use of poisonous drugs management methods for safekeeping and use) to achieve clear marking, daily inspection, to ensure that the application of any time, and a person responsible for the collection and storage.
3, regular inventory, inspection of drugs, to prevent backlogs, deterioration, found that there is precipitation, pollution, discoloration, expiration date, the bottle label does not match the bottle of drugs, labeling fuzzy or altered, shall not be used.
4, where the rescue drugs, must be placed in the rescue car, daily shift, numbered arrangement, positioning storage, to ensure that the application at any time, after use at any time to replenish.
5, the patient's personal medication, should indicate the bed number and name, stored separately, and returned to the pharmacy in a timely manner after the discontinuation of medication to avoid waste.
The second instrument management system
Medical equipment by the responsible nurse is responsible for the custody, regular inspection, to maintain good performance, every shift to be careful handover.
The use of medical equipment must understand its performance and maintenance methods, strict compliance with operating procedures, after use must be cleaned and processed, sterilized and returned to the original place.
Valuable instruments must have a person in charge of custody, should always keep the instrument clean and dry, after use by the custodian must check whether the performance is intact. A variety of instruments, should be properly stored according to its different nature.
Ten, medical accidents (nursing negligence, defects) registration, reporting, handling system
1, each department to establish errors, accidents register, timely registration of the time of occurrence, after the cause, the reason, the consequences.
2, the occurrence of errors and accidents, in line with the principle of the patient first, quickly take remedial measures to avoid or mitigate the damage to the patient's health or to minimize the damage, in order to reduce or eliminate the adverse consequences.
3, the person concerned should immediately report to the physician on duty, the head nurse, the head nurse immediately reported to the director of the department, the nursing department, the nursing department immediately reported to the vice president in charge, the Ministry of Medical Affairs. And fill out the required "nursing error registration form" reported to the Department of Nursing.
4, the occurrence of errors and accidents in a variety of relevant records, test reports and cause accidents of drugs, equipment, etc. should be properly stored, shall not be altered without authorization, destroyed for identification.
5, after the occurrence of errors and accidents, the head nurse should be organized as soon as possible to discuss the nurses in the room, in order to raise awareness, learn lessons, improve the work, and determine the nature of errors and accidents, and put forward the treatment of opinions, the written materials submitted to the Department of Nursing.
6, the occurrence of errors and accidents in the department or individual, such as not in accordance with the provisions of the report, intentional concealment, when found by the leadership or others, according to the relevant provisions of the hospital.
7, the Department of Nursing regularly organize the relevant personnel to analyze the error, the cause of the accident, put forward preventive measures, and constantly improve the nursing management.
8, processing: according to the severity of the error, were given verbal criticism, written review, economic treatment, suspension and reflection, stay on duty and other treatments.
Eleven, disinfection and isolation system
Medical personnel at work, neatly dressed, leaving the workplace should be removed from the work clothes, prohibit the wearing of work clothes into the cafeteria, meeting rooms and nurseries and other non-work places.
Diagnosis and treatment, dressing disposal before and after work should wash their hands or hand disinfection.
Aseptic containers, instruments, dressing jars, holding forceps, etc. should be disinfected and sterilized on a regular basis, the disinfectant solution should be changed regularly, and the thermometer should be sterilized for one person for one use.
The ward should be ventilated regularly, and the air sterilized when necessary. The floor should be wet cleaned and disinfected immediately in case of contamination. Bedside tables, bedheads, chairs, door handles, etc., daily wet wiping, rags should be dedicated, thoroughly disinfected after use. Regular air microbiology testing, such as the use of ultraviolet disinfection, to register the disinfection time, regular testing of ultraviolet intensity.
Changed dirty clothes and bedclothes, put in the designated place, not littered, prohibited in the ward corridor inventory. All kinds of medical equipment must be strictly sterilized after use. The medicine cup, tableware, toilet must be sterilized after use. Patients' bedding should be changed and sterilized on a regular basis.
Surgical patients with serious infections and organ transplants should be housed separately.
Patients must be discharged, transferred to the department or after the death of the final disinfection of bed linen, beds, chairs, tables and walls, should be wiped with disinfectant. Mattresses, bedding washed and disinfected or disinfected using a bed linen disinfector.
Where anaerobic bacteria, Pseudomonas aeruginosa and other special infections patients, should be strictly isolated, after the use of instruments, clothing and rooms should be strictly disinfected, used dressings should be incinerated.
Infectious patients and their belongings are handled according to the disinfection and isolation system for infectious diseases.
Aseptic articles are checked once a day, and sterilized articles (cotton balls, gauze, etc.) in the aseptic storage tanks, once opened, should not be used for more than 24 hours at the longest; small packages are used as much as possible. Used items and unused items are strictly separated and clearly labeled, and expired items are strictly prohibited.
All outpatient wards and other workplaces should be cleaned and disinfected before medical staff leave work.
Disposable medical supplies, discarded items in accordance with the provisions of the treatment, placed in special containers closed transportation, harmless treatment.
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