Medical core system 14:
First, the nursing quality management system. Ward management system. Rescue work system iv. Graded nursing system and nursing handover system. Check system seven. Surgical examination system. Supply room inspection system. Patient health education system x. Xi nursing consultation system. General disinfection and isolation management system in wards. Nursing safety management system. Nursing error and accident reporting system. Preoperative patient visiting system
Fourteenth medical core system:
First, the first-visit department is responsible for the first-visit system.
1. When an outpatient or emergency patient registers for treatment, the first-time physician should serve the patient with a high sense of responsibility, and shall not shirk the patient for any reason.
2, the first physician should seriously ask about medical history, physical examination and write medical records.
3. If you are not a patient in this college, the first-time doctor will be responsible for consulting the corresponding professional doctor.
4, critically ill patients or patients with mobility difficulties should be responsible for the first visit to the scene, please consult the relevant consultants, and be responsible for the whole process, until the diagnosis direction and admitted departments are determined.
5. In case of patients whose main diagnosis is not clear for the time being, the department where the first-time physician is located shall be responsible for temporary disposal, and then transfer to relevant departments after being diagnosed. Don't push the patient away for any reason.
Second, the clinical blood audit system
1, the doctor strictly grasps the indications of blood transfusion according to the specific condition of the patient and the requirements of clinical blood use, and decides whether the patient should use blood component or whole blood.
2. The doctor and the recipient (or client/guardian) sign a "blood transfusion treatment agreement", detailing the importance and necessity of blood transfusion and the risk of first-class blood transfusion (possible reactions and infection of blood-borne diseases).
3. Doctors should carefully fill in the Application Form for Clinical Blood Transfusion, review and sign it step by step according to regulations, and conduct routine pre-transfusion examination, including alanine aminotransferase, hepatitis B surface antigen, hepatitis B antibody, AIDS antibody and syphilis antibody.
4, clinical departments will blood samples, the clinical blood transfusion application form, the blood transfusion inspection form together to the blood bank.
5. The blood bank (inspection doctor) shall fill in the Blood Transfusion Cross Matching Inspection Report, and bring the blood recipient back to the clinical department when taking blood.
6, when the blood out of the library, by the blood recipients to check and sign.
7. After the blood is recovered by the clinical department, it shall be checked by two medical personnel and signed on the back of the "Blood Transfusion Cross Matching Test Report" for confirmation.
8. During blood transfusion, medical personnel should carefully observe whether the recipient has any adverse reactions to blood transfusion. In case of transfusion reaction, restrictive measures should be taken in time and reported step by step according to the condition. After blood transfusion, fill in the "Declaration Form of Adverse Blood Transfusion Reaction" in detail and keep it in the blood bank.
9. The Consent for Blood Transfusion Treatment, Blood Transfusion Checklist and Blood Transfusion Cross Matching Inspection Report are kept in the medical records by the clinical departments; The Application Form for Clinical Blood Transfusion, the Declaration Form for Adverse Blood Transfusion Reaction and the Registration Form for Checking Blood Infusion shall be kept by the blood bank, and relevant blood transfusion data shall be kept for 20 years for future reference.
Three, surgical grading management and examination and approval system
In order to ensure the safety and quality of surgery, prevent the occurrence of medical accidents, and strengthen the operation and management of hospitals and doctors at all levels, these Provisions are formulated in accordance with the Regulations on the Administration of Medical Institutions, the Law of People's Republic of China (PRC) on Medical Practitioners and the Regulations on the Handling of Medical Accidents, combined with the requirements of hospital classification management and basic modern hospitals, and with reference to relevant materials.
(1) business classification
Mainly according to the responsibility of the surgical process and the requirements of surgical technology, the operation is divided into:
1, Class A operation: all kinds of operations with complicated operation process and great technical difficulty.
2. Class B surgery: all kinds of major surgery with complicated surgical procedures and difficult surgical techniques.
3. Class C surgery: all kinds of medium-sized surgery with uncomplicated operation process and little technical difficulty.
4. Class D surgery: common minor surgery with simple operation process and low technical difficulty.
Note: Minimally invasive (intravascular) surgery is included in all kinds of surgery according to its technical responsibility.
(2) Classification of surgeons
According to their health technical qualifications and corresponding positions, the classification of surgeons is stipulated. All surgeons should be qualified as medical practitioners according to law.
1, resident
(1) Junior resident: those who have worked as residents for less than 3 years, or those who have worked as residents for less than 2 years after their master's degree.
(2) Senior resident: worked as a resident for more than 3 years, or graduated from a master's degree and obtained the qualification of a medical practitioner, and worked as a resident for more than 2 years.
2. Attending physician
(1) Primary attending physician: those who have served as attending physician for less than 3 years or graduated from clinical doctoral program for less than 2 years.
(2) Senior attending physician: one who has served as attending physician for more than 3 years or graduated from clinical doctoral program for more than 2 years.
3, deputy chief physician
(1) Junior deputy chief physician: one who has served as deputy chief physician for less than 3 years, or has been engaged in clinical work for more than 2 years as a postdoctoral doctor.
(2) Senior deputy chief physician: one who has served as deputy chief physician for more than 3 years.
4. Chief physician
(three) the business scope of doctors at all levels
1. Under the guidance of superior doctors, junior residents gradually develop and master type D surgery.
2. On the basis of mastering D-type operation, senior residents gradually perform C-type operation under the guidance of superior doctors.
3. Primary attending physicians are proficient in Class C surgery, and gradually carry out Class B surgery under the guidance of superior physicians.
4, senior attending physician master class B surgery, conditional can be under the guidance of the superior doctors, appropriate to carry out some class A surgery.
5. The junior deputy chief physician is proficient in Class B surgery, and gradually develops Class A surgery under the guidance of the superior physician.
6, senior deputy chief physician under the guidance of the chief physician, to carry out a class of surgery, but also according to the actual situation to complete part of a class of surgery, new surgery and scientific research projects.
7, the chief physician skilled to complete a kind of surgery, especially to complete new surgery or the introduction of new surgery, or major exploratory scientific research projects.
(four) the operation approval authority
Operation approval authority refers to the approval authority for all kinds of operations, which is the key to control the quality of operations.
1, normal operation
(1) Class A surgery: approved by the director of the department, signed by the senior deputy chief physician or above, and reported to the medical department (department) for filing. Special surgical cases must fill in the "surgical approval form", and the director of the department will report to the medical department (department) after discussing and signing the opinions according to the department, and the vice president of the business will approve it.
(2) Class B operation: with the approval of the department director, the operation notice issued by the deputy chief physician or above shall be reported to the medical department (department) for the record.
(3) Class C surgery: approved by the director of the department, and the doctor above the senior attending physician issues a notice of surgery.
(4) Class D operation: The attending physician will examine and approve the operation and issue a notice of operation.
(5) To carry out major new surgery and exploratory (scientific) surgery projects, they must be demonstrated by academic groups designated by the health department and reviewed by the medical ethics committee before they can be implemented in hospitals. Major projects involving life safety and social environment shall be reported to the relevant state departments for approval according to regulations.
2, special surgery
Any of the following operations can be regarded as special operations:
(1) The patients are foreign guests, overseas Chinese and compatriots from Hong Kong, Macao and Taiwan.
(2) Surgical patients are senior cadres, famous experts, scholars, celebrities, leaders of democratic parties and other special health care objects.
(3) disfigured or disabled for various reasons.
(4) may cause judicial disputes.
(5) The same patient needs reoperation within 24 hours.
(6) high-risk surgery.
(7) Doctors from other hospitals come to the hospital to participate in the operation. Medical practice in different places must be carried out in accordance with the relevant provisions of the Law on Medical Practitioners.
(8) Large organ transplantation.
The above operations must be discussed by the department, signed by the department director, submitted to the medical department (department) for review, approved by the business dean or dean, and issued by the deputy chief physician. Medical practitioners who practice surgery in different units and places shall go through the relevant examination and approval procedures according to the requirements of the Law on Medical Practitioners. The practice procedures of foreign doctors shall be examined and approved according to the relevant provisions of the state. In addition, in an emergency or unexpected situation, in order to save the patient's life, the attending doctor should make a decisive decision, race against time to actively rescue, and report to the superior doctor and the chief duty in time without delaying the rescue opportunity.
Fourth, the preoperative case discussion system
Preoperative discussion is necessary for major, difficult and newly developed operations. Presided over by the department director or attending physician, attended by surgeons, anesthesiologists, nurses and related personnel. Make the operation plan, postoperative observation items and nursing requirements. The discussion was recorded in the case. General surgery should also be discussed accordingly.
Five, medical record writing system
(a) medical records should be written in pen, and strive to be smooth, complete, concise and accurate. The handwriting should be clear and neat, and it is not allowed to be deleted, filled backwards or cut and pasted. Doctors should sign their full names.
(2) All medical records shall be written in Chinese, except that there is no official translation of the names of diseases and drugs. Diagnosis and operation should be filled in according to the classification names of diseases and operations.
(3) outpatient medical record writing requirements:
1. Be concise. The patient's name, gender, age, occupation, native place, work unit or residence shall be filled in by the registration room. The chief complaint, present medical history, past history, various positive signs and necessary negative signs, diagnosis or impression diagnosis, treatment and treatment opinions should be recorded in the medical record, written and signed by the doctor.
2. The interval is too long or different from the previous patients. The examination results and diagnosis should generally be the same as those of newly diagnosed patients, and the words "newly diagnosed" should be written.
3. Every consultation should be dated, and emergency medical records should be filled with time.
4. When requesting consultation in other departments, the purpose of requesting consultation and the preliminary opinions of undergraduate course should be clearly filled in the medical records.
5. The invited consultant should fill in the examination results, diagnosis and treatment opinions on the medical records requesting consultation and sign them.
6. When the outpatient needs hospitalization, the doctor shall sign and write the hospitalization certificate, and indicate the reasons for hospitalization and the initial impression diagnosis on the medical record.
7. The outpatient physician is responsible for filling in the referral medical record summary for the referral patients.
(4) Requirements for writing hospital medical records:
1. Newly admitted patients must fill in complete medical records, including name, gender, age, occupation, native place, work unit or residence, contact information, chief complaint, current medical history, past history, family history, personal life history, menstrual history, birth history, physical examination, laboratory examination, special examination, summary, preliminary diagnosis and treatment advice.
2. When writing, try to be detailed, neat and accurate. It should be completed within 24 hours after admission, and the emergency department should check and fill it out immediately.
3. The medical records shall be filled in by interns, reviewed and signed by residents, supplemented and revised when necessary, and the residents shall write another hospitalization record (admission record). If there is no intern, the resident will fill out the medical record. The attending physician should review, modify and sign.
4. Re-admission to the hospital should write a re-admission medical record.
5. After the patient is admitted to the hospital, quasi-diagnostic analysis must be carried out within 24 hours, and the diagnosis and treatment measures should be put forward and recorded in the course record.
6. The course record (course log) includes the condition change, inspection findings, differential diagnosis, analysis and diagnosis opinions of superior doctors, treatment process and effect. When special treatment is carried out, the implementation method and time shall be recorded. Generally, the course of disease is recorded once a day, and critically ill patients and patients whose condition suddenly deteriorates should be recorded at any time. The course of the disease is recorded by the attending physician, who should check it in a planned way, put forward the opinions of consent or modification and sign it.
7. The consultation and discussion of difficult diseases within the scope of the department or the whole hospital shall be recorded in detail. Ask another doctor for consultation, and the consultant will fill in the record and sign it.
8. All handover patients must fill in the course record by the succession doctor. The stage summary is filled in by the attending doctor in the course record.
9. Who decided to referral, change one's major or transfer patients, the attending physician must write a detailed record of referral, change one's major or transfer, and signed by the attending physician. The handover record is finally reviewed and signed by the department head.
10. All kinds of inspection sheets should be pasted in order.
1 1. The discharge record and death record should be completed on the same day. The contents of the discharge record include the summary of medical records and various checkpoints, the changes of illness during hospitalization, the treatment process, the effect, the situation at discharge, the treatment policy and follow-up plan after discharge, which are written by the attending physician and signed by the attending physician. In addition to the medical record summary and treatment process, the death record should also record the rescue measures, the time of death and the cause of death, which should be written by the attending physician and signed by the attending physician. All patients who do pathological anatomy should have detailed pathological anatomy records and pathological diagnosis. The discussion of death records should also be recorded in detail.
Six, ward round system
1. The director, chief physician or attending physician should have residents, head nurses and related personnel to attend the rounds. The director and chief physician (including deputy chief physician) make rounds 1-2 times a week, and the attending physician makes rounds once a day, usually in the morning. Residents should make rounds at least twice a day.
2. For critically ill patients, residents should observe the changes of their condition at any time and handle them in time. When necessary, the attending physician, department director and chief physician may be invited to examine the patient temporarily.
3. Before rounds, medical staff should make preparations, such as medical records, X-rays, relevant inspection reports and required inspection equipment. When making rounds, we should be strictly responsible from top to bottom. Residents receiving treatment should report the brief medical history, current illness and put forward the problems that need to be solved. The director or attending physician can make necessary examination and condition analysis according to the situation, and make positive instructions.
4. The head nurse organizes nursing staff to conduct nursing rounds once a week, mainly to check the quality of nursing, study and solve difficult problems, and combine practical teaching.
5. Contents of rounds:
(1) The director and chief physician make rounds to solve difficult cases; Review the diagnosis and treatment plan of newly admitted and critically ill patients; Decide on major surgery and special examination and treatment; Spot check the doctor's advice, medical records and nursing quality; Listen to the opinions of doctors and nurses on diagnosis and treatment nursing; Carry out the necessary teaching work.
(2) the attending physician rounds, requiring patients to be responsible for grouping system rounds. In particular, it focuses on the examination and discussion of patients newly admitted to hospital, with serious illness, unknown diagnosis and poor treatment effect; Listen to the reflection of doctors and nurses; Listen to the patient's statement; Check the medical records and correct the wrong records; Understand the patient's condition changes and solicit opinions on diet and life; Check the implementation of the doctor's advice and the treatment effect; Deciding to leave and transfer.
(3) The residents' rounds require that the patients who are critical, difficult, waiting for diagnosis, newly admitted to hospital and after operation be inspected, and the general patients be inspected at the same time; Check the inspection report, analyze the inspection results, and put forward suggestions for further inspection or treatment; Check the implementation of the doctor's advice on that day; Give the necessary temporary medical advice and write the medical advice for special inspection the next morning; Check the patient's diet; Actively solicit patients' opinions on medical treatment, nursing and life.
Seven, to carry out new technology and new methods access management system.
A, this unit has not been developed, the applicant has no operating experience of new technologies and methods, and the technology and methods may directly lead to the death and disability of patients, must be agreed by the patients and their families and perform the signing procedures, submit a written application to the medical department, which will organize relevant experts and relevant departments in conjunction with the science and education department to conduct relevant argumentation, put forward opinions and report to the competent dean for approval before carrying out. Before the implementation process, the applicant should clearly explain the possible accidents to the patients and their families, and report to the medical department at any time during the implementation process so as to take various preventive measures.
Two, the unit did not carry out, the applicant has experience in new technologies and methods, and the technology and methods may directly lead to the death and disability of patients; It is necessary to submit a written application to the medical department, which can only be carried out after the approval of the medical section chief, the consent of patients and their families, and the signing procedures.
Three, new technology, new method after the completion of 3 cases, must submit a summary report to the medical department, the medical department according to the situation to decide whether to continue the examination and approval.
Eight, check the system
First, the doctor's advice check system
(1) When copying doctor's orders, the date, time and signature of the original doctor's orders and the copied doctor's orders must be stated. After copying the doctor's advice, it must be checked before execution, and every BANCHA should be checked. The head nurse takes part in a comprehensive examination twice a week.
(2) Temporary immediate execution of doctor's advice can only be carried out after two people check it. And record the execution time and the signature of the executor.
(3) When rescuing a patient, the doctor verbally gives an order, and the executor must repeat it and then execute it. And urge doctors to make it up in time.
Two, medication, injection, infusion inspection system
(1) Before taking medicine, injection and infusion, the "three checks and seven pairs" must be strictly implemented: seven pairs should be checked before, during and after operation: bed number and name, drug name, dosage, concentration, time and usage should be checked.
(2) Check the quality before dispensing, pay attention to whether there is deterioration, whether there is looseness or crack in the bottle mouth, and the expiration date and batch number do not meet the requirements or the label is unclear, and shall not be used.
(3) After dispensing, it can only be implemented after being checked by the second person.
(4) Ask whether there is allergic history before taking the medicine; The use of toxic, anesthetic and drama-limiting drugs should be checked repeatedly; After taking the medicine, keep the ampoule so that it can be checked correctly when necessary. When giving a variety of drugs, pay attention to whether there are compatibility taboos.
(5) When dispensing and injecting drugs, if patients ask questions, they should find out in time before implementation.
Third, the blood transfusion inspection system
(1) Check the date of blood collection, the validity period of blood, the presence of blood clots and hemolysis, and the presence of air leakage and cracks in the blood bag.
(2) Check whether the name, blood type and blood bag number of the blood donor on the blood transfusion card are consistent with the label on the blood bag, and whether there is coagulation reaction in the cross matching test.
(3) The patient's bed number, name, hospitalization number, blood type, blood bag number and the amount of blood transfusion applied.
(4) Before blood transfusion, it must be checked by two people, and it can be input only after it is confirmed.
(5) Save the blood bag for a short time after blood transfusion, so as to check it when necessary.
Four, surgical patients check system
(1) When preparing and receiving patients before operation, the patient's bed number, name, sex, age, diagnosis, surgical site, name and preoperative medication should be checked. Drug allergy test results, according to the requirements of positioning.
(2) Check whether the sterilization index in the aseptic package meets the requirements and whether the surgical instruments are complete.
Nine. consultation system
1. In case of difficult cases, you should apply for consultation in time.
2. Cross-departmental consultation: proposed by the attending physician, with the consent of the superior physician, fill in the consultation form. The invited doctor usually finishes it in two days and writes the consultation record. For mild patients who need specialist consultation, they can go to a specialist for examination.
3. Emergency consultation: Invited personnel must be on call. General emergency consultation is completed by the attending physician, signed by the superior physician, and marked "urgent" on the consultation form, inviting the department physician to arrive within one hour; The emergency department with special illness should contact by telephone first, and then fill in the consultation form, or indicate the word "urgent" on the consultation form. The invited department doctor must go immediately (arrive within 20 minutes) without delay.
4. Intra-department consultation: proposed by the attending physician or attending physician, and the director of the department calls relevant medical personnel to participate.
5. In-hospital consultation: proposed by the director of the department, agreed by the medical department, determined the consultation time, and informed relevant personnel to attend. Generally presided over by the director of the application department, the medical department should participate.
6. Out-of-hospital consultation: Difficult cases that cannot be diagnosed and treated in our hospital at the moment shall be proposed by the department director, agreed by the medical department, and contacted with relevant units to determine the consultation time. Please ask the hospital to appoint a department director or attending physician for consultation. The consultation will be presided over by the director of the application department. If necessary, bring medical records and accompany patients to consult outside the hospital. Medical records can also be sent to relevant units for written consultation.
7. In-department, in-hospital and out-of-hospital group consultation: The attending physician should introduce the medical history in detail, make preparations before consultation and make consultation records. In the process of consultation, it is necessary to conduct a detailed inspection, carry forward technical democracy, and clearly put forward consultation opinions. The host should make a summary and seriously organize the implementation.
X. Death case discussion system
All death cases should generally be held within one week after death, and special cases should be discussed in time. Autopsy cases will be discussed after the pathological report is issued, but not later than two weeks. The discussion shall be attended by the director of the department, medical staff and relevant personnel, and the medical department shall be invited to send someone to attend if necessary. The discussion is recorded in the medical record.
XI。 Difficult case discussion system
Where there are difficult cases in the department, they have not been diagnosed for three days after admission, and the treatment effect is not good for three days, and the condition is serious, so the infected people in the hospital need to be discussed. The seminar is presided over by the department director or attending physician, and relevant personnel from undergraduate or other departments are invited to attend, so as to make a clear diagnosis and modify the treatment plan as soon as possible.
Twelve, critically ill patients rescue system
A, critically ill patients rescue work organized by the attending physician, director and head nurse, and telephone or written report to the medical department. When necessary, hospital leaders take part in the command. All rescue workers should obey the leadership and command, be serious and responsible, and work together with Qi Xin to actively rescue patients.
Two, the diagnosis, treatment, technical operation and other issues in the rescue work, should be promptly asked and invited to solve the relevant departments through consultation.
Three, doctors and nurses should cooperate closely, oral doctor's advice nurses should repeat it, check and correct the rear can perform.
Four, do a good job in rescue records, accurate, clear, concise and complete, and accurately record the execution time.
Five, new admission or mutation of critically ill patients, should promptly notify the medical department or the section chief on duty, fill in the "critical notice" in triplicate, respectively, to the patient's family, the medical department and posted on the medical record, after being stable, posted on the back of the medical record home page, and promptly notify the medical department of the rescue results.
Thirteen, duty, succession system
(a) the doctor on duty and succession:
1. There are doctors on duty during non-office hours and holidays, and one person is on duty.
2. The doctor on duty every day before coming off work in the department to accept the medical work assigned by doctors at all levels. During the shift change, you should patrol the ward, understand the situation of critically ill patients, and make a good handover before going to bed. The successor shall not leave his post before his arrival.
3. The doctor on duty before coming off work should record the condition and treatment of critically ill patients in the log book, and make a good log book. The doctor on duty should record the course of disease and medical measures of critically ill patients, and make a brief record in the duty log.
4. The doctor on duty is responsible for temporary medical work and the patient's temporary situation; Check and fill in the medical records of emergency patients in time and give necessary medical treatment.
5. The doctor on duty in case of difficult problems, should be handled by the attending physician or superior doctors.
6. The doctor on duty must stay in the duty room at night and shall not leave without authorization. The nurse should see the doctor at once when invited. If you have something to leave, you must explain it to the nurse on duty.
7. At the daily morning meeting, the doctor on duty will report the patient's situation to the attending physician or chief physician, and make clear to the attending physician the situation of critically ill patients and the work to be handled.
(2) the nurse on duty and succession:
1. Undergraduate course implements 24-hour three-line value.
2. The personnel on duty should strictly follow the doctor's advice, obey the arrangement of the head nurse, stick to their posts, perform their duties, and ensure the accurate and timely treatment and nursing work. Nurses are not allowed to change shifts without the consent of the head nurse.
3. In strict accordance with the requirements of graded nursing patrol patients, found within the scope of responsibility of illness change to give disposal, and reflect to the doctor on duty. In case of major problems, report to the head nurse and head teacher in time.
4. Each shift must be handed over on time, and the successor must report to the department and the temperature shift 15 minutes in advance to hand over the goods. The successor shall not leave his post before his arrival.
5. Before the succession, the personnel on duty must complete all the records and work of the class and handle the used items. In case of unfinished work under special circumstances, it is necessary to explain in detail to the next shift and do a good job with the successor before leaving.
6. Every morning, the night shift report is read by the night shift nurse, and the head nurse explains related matters and comments on simple work. Time should not exceed 15 minutes. After the meeting, the head nurse led the day shift and night shift nurses to patrol the ward to check the patient's condition and ward management.
7. Oral and bedside handover at noon. Other courses require written, oral and bedside handover.
8. Written succession should be written in accordance with the requirements of Jiangsu medical record writing specification. Oral and bedside handover contents include the implementation of this version of the doctor's advice, the completion of various treatments, whether there are bedsores and the completion of basic care for critically ill patients such as coma, paralysis and primary care, and the fixation and drainage of various catheters.
9. The number and efficiency of each class's face-to-face handover station, treasure, poison, hemp, limit, drama medicine and rescue articles, equipment and instruments. Successors should be responsible for the problems found in the process of succession. If the handover is unclear, there are mistakes or items are lost after the succession, the successor shall be responsible.
Fourteen, grading nursing system
1. Inpatients are registered by doctors according to their conditions and orders, and are divided into four types: I, II and III nursing and special nursing. Nursing staff should add nursing grade identification to patients' bedside cards.
Two. Special care
1. Disease basis
(1) Critical patients who need to be rescued and monitored at any time.
(2) Major operations with complicated conditions or newly developed major operations, such as organ transplantation.
(3) All kinds of severe external and extensive burns.
2. Nursing requirements
(1) Designate a special person to take care of the patient, closely observe the illness, prepare first-aid medicines and equipment, and be ready for rescue at any time.
(2) Make a nursing plan and establish a special nursing record sheet. Observe the changes of patients' vital signs at any time according to their illness and record the amount of entry and exit.
(3) Do the basic nursing carefully to prevent complications and ensure the safety of patients.
Three. Primary health care
1. Disease basis
(1) Those who are seriously ill, critically ill, after various major operations, need absolute bed rest and cannot take care of themselves.
(2) Various internal bleeding or trauma, high fever, coma, liver and kidney failure, shock and extreme weakness.
(3) paralysis, convulsion, eclampsia, premature infants and cancer treatment period
2. Nursing requirements
(1) Stay in bed absolutely, and meet various requirements of life.
(2) Pay attention to emotional changes, do ideological work well and give meticulous care.
(3) Observe the condition closely, patrol once every 15-30 minutes, regularly measure body temperature, pulse, respiration and blood pressure, make a nursing plan according to the condition, observe the reaction and effect after taking the medicine, and make various nursing records.
(4) Strengthen basic nursing, do oral care and skin care regularly to prevent complications.
(5) Strengthen nutrition, encourage patients to eat, keep the room clean and tidy, keep the air fresh, and prevent cross infection.
Four. Secondary health care
1. Disease basis
(1) Patients with acute symptoms in critical period, stable condition after special complicated operation and major operation, still needing to stay in bed for bone traction and lying in plaster bed, and unable to take care of themselves.
(2) The elderly, infirm or chronically ill should not be too active.
(3) Patients with general postoperative or mild threatened epilepsy.
2. Nursing requirements
(1) Stay in bed and do light activities in bed according to the patient's condition.
(2) Observe the changes of the disease, carry out special treatment and the reaction and effect after medication, and patrol every 1-2 hours/time.
(3) Do basic nursing, help turn over, strengthen oral and skin care, and prevent complications.
(4) Give necessary care in life. Such as washing your face, blowing your body, delivering meals, delivering toilets, etc.
Verb (abbreviation of verb) tertiary nursing
1. Disease basis
(1) Mild symptoms, general chronic diseases, preoperative examination preparation stage, normal parturient, etc.
(2) Patients recovering from various diseases or about to leave the hospital.
(3) you can get out of bed and take care of yourself.
2. Nursing requirements
(1) You can get out of bed and take care of yourself.
(2) Measure the body temperature, pulse and breathing twice a day to master the life and thoughts of patients.
(3) urge patients to abide by hospital rules and regulations, ensure rest, pay attention to diet, and patrol twice a day.
(4) Providing consultation and guidance on maternal and child health care.