1. Which steps are included in the nursing process?
The nursing process consists of five steps: assessment, diagnosis, planning, implementation, and evaluation.
2. What are the methods of data collection?
①Observation; ②conversation; ③physical examination; ④consultation of relevant information.
3. What should be the appropriate temperature and humidity in the sickroom?
(l) The temperature of the room is generally maintained at 18-22℃. Newborns and elderly patients, the room temperature is maintained at 22-24 ℃ is appropriate.
(2) The humidity of the room is generally maintained at 50% to 60%.
4. What are the common lying positions? Which patients are suitable for each of them?
(1) decubitus supine position: for coma or general anesthesia is not awake patients; intrathecal anesthesia or spinal cord cavity after puncture patients.
(2) Mid-concave position: for patients in shock.
(3)Flexed-knee supine position: for patients undergoing abdominal examination or undergoing catheterization or perineal irrigation.
(4) Side-lying position: for patients with enema, anal examination and with gastroscopy and enteroscopy; patients with intramuscular injection in the buttocks.
(5) Semi-sitting position: for patients with respiratory distress caused by cardiopulmonary diseases; patients after thoracic, abdominal and pelvic surgery or with inflammation; patients after certain facial and neck surgeries; patients with weak constitution during the recovery period.
(6) Sitting position: for patients with heart failure, pericardial effusion, and bronchial asthma attacks.
(7) Prone position: for patients with lumbar and back examination or when cooperating with pancreatic and cholangiography; patients who cannot lie flat or sideways after spinal surgery or with wounds on the waist, back, or buttocks; patients with abdominal pain due to gastrointestinal distension.
(8) Head-down, foot-up position: for patients with drainage of pulmonary secretions; patients undergoing duodenal drainage; patients with premature rupture of membranes in pregnancy; patients with heel or tibial tubercle traction.
(9) Head-high-foot-low position: for patients with cervical spine fracture for cranial traction; patients after cranial surgery.
(10) Knee-thorax position: for patients with anal, rectal, and sigmoidoscopic examination and treatment; patients who need to correct fetal malposition or uterine tilt. Patients; to promote postpartum uterine recovery.
(11) Amputation position: for patients with perineal and anal area examination, treatment or surgery; maternal delivery.
5. What are the precautions to be taken when changing the lying position for special patients?
(1)For those who have various catheters or infusion devices,l the catheter should be properly placed first, and carefully checked after turning over to keep the catheter clear.
(2) For those with cervical or cranial traction, do not relax the traction when turning over and keep the head, neck, and torso at the same level; after turning over, pay attention to the direction and position of traction as well as whether the traction force is correct.
(3) Craniocerebral surgery, should take the healthy side of the lying position or lying position, in the turn over to pay attention to the head should not be violent flip, so as not to cause brain hernia, compression of the brain stem, resulting in the sudden death of the patient.
(4)For those who are fixed in plaster, attention should be paid to the position of the affected area and the blood circulation of the local limbs after turning over to prevent pressure.
(5) general surgery, turn over the crack Xiao body should first check whether the dressing is dry, there is no shedding, such as secretion wet dressing, should be replaced and fixed properly before turning over, turn over the wound should not be bored after pressure.
6. What are the precautions for the use of restraints?
(1) Strictly grasp the indications for the application, pay attention to maintain the patient's self-esteem.
(2) Explain to the patient and his family the purpose, operation points and precautions for the use of restraints, in order to obtain understanding and cooperation.
(3) Restraints should only be used for a short period of time and should be released at regular intervals, and the patient should be assisted in changing positions frequently.
(4)The limb is in a functional position when used; the restraining belt needs to be padded under the padding, and the tightness is appropriate; the skin color of the restraining area is closely observed, and local massage is carried out when necessary to promote blood circulation.
(5) Record the reason for the use of restraints, time, observation results, nursing measures and the time to release the restraint.
7. What are the components of pain assessment?
①Part of the pain;
②Time of the pain;
③Nature of the pain;
④Degree of the pain;
⑤Mode of expression of the pain;
⑥Factors affecting the pain;
⑦Impact of the pain on the patient, with or without accompanying symptoms.
8, What are the commonly used pain assessment tools?
①Numerical assessment method;
②Textual descriptive assessment method;
③Visual analog assessment method;
④Facial expression measurement chart.
9. How to apply the 0-5 textual descriptive rating method to assess pain?
Level 0 No pain.
Grade 1 mild pain: tolerable, can live and sleep normally.
Grade 2 moderate pain: mildly interferes with sleep, requires pain medication.
Grade 3. Severe pain: interferes with sleep and requires narcotic pain medication.
Grade 4 severe pain: heavy sleep disturbance, accompanied by other symptoms.
Grade 5 intolerable: severe thousand disturbed sleep with other symptoms or passive position.
10. What are the stages of pressure ulcers? Briefly describe the reasons for their occurrence.
Based on its severity and depth of invasion, it can be divided into four phases:
1) bruising and reddish infiltration stage;
2) inflammatory infiltration stage;
3) shallow ulceration stage;
4) necrotic ulceration stage.
Causes:
(1) Localized long-term pressure, friction or shear force.
(2) Localization is often stung by moisture or excreta.
(3) Improper use of plaster bandages and splints.
(4) Generalized malnutrition or edema.
11. Briefly describe the scales of mobility of the body.
0 degree: fully independent and free to move around.
1 degree: need to use equipment or devices (e.g., crutches, wheelchair).
2 degrees: requires assistance, supervision and education from others.
3 Degree: needs both someone's help and equipment and devices.
4 degrees: completely unable to be independent and participate in activities.
12. Briefly describe the grading of muscle strength.
Grade 0: complete paralysis with total loss of muscle strength.
Grade 1: Slight muscle contraction is seen but no limb movement.
Grade 2: Position can be moved but not lifted.
Grade 3: Limb can be lifted away but not against resistance.
Grade 4: Can make movements against resistance but muscle strength is reduced.
Grade 5: Normal muscle strength.
13. How do you measure pulse rate in a patient with a short pulse?
To measure the pulse rate of a patient who has a short pulse, two people should measure at the same time. One person should listen to the heart rate and the other should measure the pulse rate, and both people should start at the same time, and the one who listens to the heart rate should give the command of "start" and "stop", and then the time should be one minute.
14. What are the precautions for measuring blood pressure?
(1) Regularly test and calibrate the sphygmomanometer.
(2) For those who need to observe the blood pressure closely, there should be four rules, i.e., fixed time, fixed part, fixed position and fixed sphygmomanometer.
(3) When blood pressure is found to be inaudible or abnormal, it should be retested.
(4) Pay attention to the error of blood pressure measurement caused by the pressure measuring device (sphygmomanometer, stethoscope), the measurer, the examinee, and the measuring environment, in order to ensure the accuracy of blood pressure measurement.
15. What is the effect of a loose or tight cuff on blood pressure when measuring the most blood pressure?
(1) If the cuff is wrapped too loosely, the air bag will be ballooned and the effective measurement area will be narrowed, resulting in a high blood pressure.
(2) If the cuff is wrapped too tightly, the blood vessels will be compressed before gas is injected, and the measured blood pressure will be low.
16. What is tidal breathing?
Tidal respiration refers to breathing from shallow slow to deep fast, then from deep fast to shallow slow, after a period of respiratory pause (5^-3. seconds), and then repeat the above cycle of respiration, week after week like the ebb and flow of the tide.
17. What are the contraindicated parts of cold therapy? Why?
(1) behind the pillow, auricle, scrotum: to prevent frostbite.
(2) precordial area: to prevent reflex slowing of heart rate, atrial fibrillation or atrioventricular block.
(3) Abdomen: to prevent diarrhea0
(4) Plantar: to prevent reflex peripheral vasoconstriction that interferes with heat dissipation or causes transient coronary artery constriction.
18. What are the contraindications to heat therapy?
(1) Acute abdominal pain not clearly diagnosed.
(2) Infection in the danger triangle of the face.
(3) Bleeding from various organs.
(4) Initial stage (within 48h) of soft tissue injury or sprain.
(5) Eczema of the skin.
(6) Acute inflammatory reactions, such as dental achalasia, otitis media, and conjunctivitis.
(7) Metal graft sites.
(8) Sites of malignant lesions.
19. What should be assessed before nasal feeding?
(1) Whether the gastric tube is in the stomach and clear, make sure the tube is in the stomach before injecting.
(2) Whether there is any gastric retention, if the pumped gastric contents >100ml, then suspend nasal feeding.
20. What is the 24h urine output of a normal person? What is polyuria, oliguria, anuria?
Normal 24h urine volume is about 1000-2000ml, average 1500ml.
Polyuria: refers to the 24h urine volume often more than 2500ml.
Small urine: refers to the 24h urine volume is less than 400ml or less than 17ml per hour.
Anuria: also known as urinary closure, refers to the 24h urine volume is less than 100ml or 12h without urine. no urine in 12h.
21. Briefly describe the method of collection of 24h urine specimen.
(1) Empty the bladder at 7:00 a.m., and collect all urine thereafter in a large clean container (such as a clean sputum Meng), and then at 7:00 a.m. the next morning, empty the container for the last time, measure the total amount of urine, and write it down on the lab sheet.
(2) Mix all the specimens well, take out about 20 ml of specimens from them, put them in a clean and dry container and send them for examination as soon as possible.
(3) For some special tests, preservatives need to be added as appropriate.
22. What are the common pathologic changes in urine color?
(1) hematuria: the shade of the color is related to the amount of red blood cells contained in the urine, the amount of red blood cells contained in the wash water color.
(2)Hemoglobinuria: a large number of red blood cells are destroyed in the blood vessels, showing a strong tea color, soy sauce-like color.
(3)Bilirubinuria: the urine is dark yellow or yellowish brown, and the foam is also yellow after oscillating the urine.
(4)Celiac disease: the urine contains lymphatic fluid and is milky white.
(5)Pus urine: urine contains pus, white flocculent turbid and can be seen containing pus filaments.
23. What are the nursing measures for acute urinary retention?
(1) Relieve the cause.
(2) Promote urination: for postoperative patients with urinary retention give induction of urination, catheterization under aseptic operation if necessary, and good care of urinary catheter and urethral opening. For patients who have undergone suprapubic cystocentesis or suprapubic cystostomy, the care of the cystostomy tube should be done well and kept open.
(3) Avoid bladder bleeding: the volume of urine released at one time should not exceed 1000ml to avoid bladder bleeding.
24. What are the key points of skin care for patients with urinary incontinence?
(1) Keep the bed sheet clean, flat and dry.
(2) Clean the perineal skin in a timely manner, keep it clean and dry, and apply skin protectant if necessary.
(3) According to the condition of the corresponding protective measures, male patients can use urinary condom, female patients can use urinary pads, urinary collector or indwelling urinary catheter.
25. What principles should be followed when administering drugs?
(1) Accurate administration of drugs according to the requirements of the doctor's orders: strict implementation of the doctor's orders, the doctor's orders in doubt should be clearly understood before giving the drug, to avoid blind implementation.
(2) Strictly implement the "three check seven right" system.
(3) Safe and correct administration of drugs: rational control of the time and method of administration, timely distribution of drugs after preparation for use. Explain and give guidance on the use of drugs before administration. For drugs that are prone to allergic reactions, understand the history of allergy before use.
(4) Observation of drug reactions: drug efficacy, adverse reactions, changes in the patient's condition, dependence on the drug, emotional reactions.
26. What are the precautions when administering drugs orally?
(1)Drugs that need to be swallowed are usually taken with warm boiled water at 40 to 60 degrees Celsius, do not take the drug with tea.
(2) Drugs that have corrosive effects on the dental step, such as acids and iron, should be sucked through a straw and then rinsed to protect the teeth.
(3) Slow-release tablets, enteric-coated tablets and capsules should not be chewed when swallowed.
(4) Sublingual tablets should be placed under the tongue or between the membranes of the cheeks and the teeth to be dissolved.
(5) Antibiotics and sulfonamides should be taken punctually to ensure effective blood levels.
(6) Drinking water should not be taken immediately after taking drugs that play a calming effect on the respiratory mucosa. Information from ICU nursing home weibo public **** number, please pay attention.
(7)Some sulfonamides are excreted by the kidneys, and crystals are easily precipitated to block the renal tubules when urine is scarce, so drink more water after taking the drugs.
(8) In general, stomachic drugs should be served before meals, digestive drugs and drugs that stimulate the gastric mucosa should be served after meals, and hypnotic drugs should be served before bedtime.
27. What are the precautions for oral iron therapy?
(1) In order to minimize gastrointestinal reactions, it can be taken after or during meals, starting with a small dose and gradually increasing to the full amount.
(2) Liquid iron can stain the teeth, so it can be taken with a straw or dropper.
(3) Iron can be taken with vitamin C;, fruit juice, etc., to facilitate absorption; avoid taking with foods that inhibit iron absorption.
(4) After taking iron, the stool becomes black or tarry. Recovery after stopping the drug, should explain the reason to the patient, eliminate concerns.
(5) Take the medication according to the dose and regimen, and review relevant laboratory tests regularly.
28. What kinds of oral care solutions are commonly used? What is the function of each?
Saline saline to clean the mouth, top prevent infection;
1% a 3% hydrogen peroxide solution antiseptic, anti-odor, for oral infections with ulceration, necrotic tissue
1% a 4% sodium bicarbonate solution alkaline solution for fungal infections
0.02% Chlorhexidine solution to clean the mouth, a broad-spectrum antibacterial
0.02% furacilin solution to clean the mouth, a broad-spectrum antibacterial
0.02% furacilin solution for the mouth. Furacilin solution cleanses the mouth, broad-spectrum antimicrobial
0.1% acetic acid solution for Pseudomonas aeruginosa infections
2% to 3% n boric acid solution acidic antiseptic, bacteriostatic
0.08% metronidazole solution for anaerobic infections
29. What types of oxygen therapy are there? For which type of patients is each indicated?
(1)Low concentration oxygen therapy: oxygen concentration <40%. Applicable: patients with hypoxemia with carbon dioxide storage, such as chronic obstructive pulmonary disease.
(2)Medium concentration oxygen therapy: oxygen concentration of 40% to 60% 0 for patients with significant ventilation/perfusion imbalance or significant diffusion disorders, such as pulmonary edema, myocardial infarction, shock and so on.
(3) High concentration oxygen therapy: oxygen concentration >60% or more. It is suitable for patients with simple hypoxia without carbon dioxide storage, such as adult respiratory distress syndrome, life support stage after cardiopulmonary resuscitation.
(4) Hyperbaric oxygen therapy: refers to the inhalation of 100% oxygen at a pressure of 2-3kg/cm2" in a special pressurized chamber, such as carbon monoxide poisoning, gas gangrene, etc..
30.Briefly describe the precautions of oxygen therapy.
(1) Emphasize the cause of the disease.
(2) Keep the airway open.
(3) Choose the appropriate mode of oxygen therapy.
(4) Pay attention to humidification and warming.
(5) Regularly change and clean dip sterilization to prevent contamination and catheter blockage.
(6) Evaluation of the effectiveness of oxygen therapy.
(7) Prevention of explosion and fire.
31. Oxygen concentration and oxygen flow rate how to convert?
Oxygen concentration (%)=21+4*oxygen flow rate (L/min)
32. What are the precautions for oxygen nebulization inhalation?
(1) Shoot the correct use of oxygen supply device, pay attention to the safety of oxygen, oxygen humidification bottle do not hold water, so as not to be diluted to avoid the efficacy of the drug.
(2)When nebulizing, instruct the patient to hold his breath for 1--2 seconds after deep and long inhalation through the mouth, and exhale through the nose, with an oxygen flow rate of 6--8L/min.
(3)Pay attention to the observation of sputum discharge of the patient, and assist the patient in cleaning the mouth after nebulizing.
33. What are the clinical manifestations of penicillin anaphylaxis?
(1) Respiratory obstruction symptoms: chest tightness, shortness of breath with a sense of dying.
(2) Circulatory failure symptoms: pale, cold sweat, sent, weak pulse, blood pressure drop, irritability.
(3) Central nervous system symptoms: manifested as dizziness, numbness of face and limbs, loss of consciousness, convulsions, incontinence and so on.
(4) Other allergic reaction manifestations: there may be urticaria, nausea, vomiting, abdominal pain and diarrhea.
34. Briefly describe the emergency care measures for penicillin anaphylaxis.
(1) Immediately stop the drug and make the patient lie down on the spot.
(2) Immediately inject 0.1% epinephrine hydrochloride subcutaneously. 0.5-1 ml, patient discretion. If the symptoms are not relieved, the drug can be injected subcutaneously or intravenously 0.5ml every 30min.
(3)Oxygen inhalation. When respiration is inhibited, mouth-to-mouth artificial respiration should be carried out immediately and intramuscular injection of respiratory anesthesia mixture. When laryngeal edema affects respiration, tracheal intubation should be prepared immediately or tracheotomy should be performed in conjunction.
(4) Anti-allergy.
(5) Correction of acidosis and administration of antihistamines as prescribed.
(6) If cardiac arrest occurs, immediately perform cardiopulmonary resuscitation.
(7) Closely observe the vital signs, urine output and other changes in condition, pay attention to warmth, and make a good record of the dynamic condition. Patients should not be moved before they are out of the danger period.
35. How are venipuncture tools categorized?
Based on the type of vessel in which the catheter is placed, it can be divided into: peripheral venous catheter, central venous catheter. According to the length of the catheter, it can be categorized as: short catheter, medium length catheter, long catheter.
36. How to flush and seal an indwelling intravenous catheter?
(1)Method of flushing: The flushing solution is usually saline, and a pulsatile flushing method is used. Peripheral indwelling needles can be flushed with a 5ml syringe; picc catheters should be flushed with a syringe of 10ml or more. The minimum amount of flushing solution should be two times the volume of the catheter and add-on device.
(2) Tube sealing method:
①Steel needle method: leave the tip of the needle inside the heparin cap for a little while, and when 0.5-1 ml of sealing solution is left in the pulsatile push, push the sealing solution while pulling out the needle (the speed of pushing the solution is greater than the speed of pulling out the needle), to make sure that the indwelling catheter is full of sealing solution, so that there is no medicine or blood in the catheter.
②No needle connector method: punch the tube before removing the syringe will be as close as possible to the puncture point of the small clip, clip after the small clip to remove the syringe.
37. What are the clinical manifestations of common infusion reactions?
(1)Fever reaction: it occurs several minutes to one hour after infusion. Manifestations of chills, chills, fever. In mild cases, the body temperature is about 38 ℃, and can return to normal within a few hours after stopping the infusion; in severe cases, the chills at the beginning, followed by high fever, the body temperature can reach 40 ℃ or more, and accompanied by headache, nausea, vomiting, rapid pulse and other systemic symptoms.
(2)Acute pulmonary edema: patients suddenly appear dyspnea, chest tightness, coughing, coughing pink foamy sputum, severe sputum can be gushed from the mouth, nasal cavity. Auscultation of the lungs is covered with wet gong sounds, and the heart rate is fast and arrhythmic.
(3) Phlebitis: streaks of red lines along the veins, local tissue redness, swelling, burning, pain, sometimes accompanied by chills, fever and other systemic symptoms.
(4)Air embolism: the patient feels abnormal discomfort in the chest or has retrosternal pain. Dyspnea and severe emanation with a sense of imminent death occur immediately. A loud, persistent "blistering sound" can be heard in the precordial area on auscultation.
38. Briefly describe the causes and management of acute pulmonary edema during infusion.
Causes:
(1) Infusion rate is too fast, too much fluid is infused in a short period of time, so that the circulating blood volume increases sharply and the heart is overloaded.
(2) The patient's original cardiopulmonary dysfunction.
Treatment measures:
(1) Immediately stop the infusion and notify the doctor for emergency treatment. If the condition permits, the patient can be made to sit up, legs down, in order to reduce the venous return of the lower limbs, reduce the burden on the heart.
(2)Give the son of high-flow oxygen inhalation, the general oxygen flow rate of 6-8L/min. At the same time, the humidification bottle with 20% --- 30% of the ethanol solution.
(3)Give sedative, asthma, cardiotonic, diuretic and vasodilator drugs as prescribed by the doctor.
(4) Perform rotational bandaging of the extremities if necessary. Appropriate pressure with rubber tourniquet or sphygmomanometer cuff to block venous blood flow, every 5-10min rotation to relax the tourniquet on one limb, can effectively reduce venous return blood volume. After the symptoms are relieved, the tourniquet is gradually released.
39. What position should the patient take when air embolism occurs during infusion? Why?
The patient should be placed in the left lateral position and kept in the head-down-foot-up position. This position facilitates the floating of gas to the right ventricular apex, avoiding the population of the pulmonary arteries, and with cardiac contraction and expansion, the air is mixed into bubbles that enter the pulmonary arteries in small amounts and are gradually absorbed.
40.What are the precautions in the use of mannitol?
(l) Intramuscular or subcutaneous injection is strictly prohibited to avoid drug leakage causing subcutaneous edema or tissue necrosis.
(2) It should not be mixed with other medications.
(3) When intravenous drip, it is preferable to use a large-gauge needle, 250 ml of liquid should be completed within 20-30 min.
(4) In the process of applying the dehydrating agent, the amount of discharge, blood pressure, pulse, respiration should be closely observed and recorded.
(5) It can increase blood volume rapidly, and is contraindicated in patients with cardiac insufficiency and acute pulmonary edema.
41. According to the type of antigen on the red cell membrane. What are the types of blood groups?
(1) Type A: only A antigen on the red blood cell membrane.
(2) Type B: those who have only B antigen on the red blood cell membrane.
(3)AB type: those who have both A and B antigens on the erythrocyte membrane.
(4) Type O: those who have neither A nor B antigen on the erythrocyte membrane.
42. What are the precautions for component blood transfusion?
(1) Certain component blood, such as white blood cells, platelets, etc. (except red blood cells), has a short survival period, and it is preferable to use fresh blood, which must be transfused into the body within 24h (from the beginning of blood collection).
(2) In addition to plasma and albumin preparations, various other components of blood need to be cross-matched before transfusion.
(3) Antiallergic drugs are given according to medical advice before transfusion.
(4) If the patient needs to be transfused with whole blood at the same time as component blood. Then component blood should be transfused first, followed by whole blood, to ensure that the component blood can exert the best effect.
43. What are the common transfusion reactions?
①Fever reaction;
②Allergic reaction;
③Hemolytic reaction;
④Large amount of blood transfusion reaction;
⑤Bacterial contamination reaction;
⑥Disease infection and so on.
44. How to deal with allergic reaction in blood transfusion?
(1) Mild allergic reaction, slow down the speed of blood transfusion and give anti-allergic drugs.
(2) For moderate or severe allergic reaction, blood transfusion should be stopped immediately, and 0.1% epinephrine should be injected subcutaneously. 0.5-1 ml, and antiallergic drugs such as dexamethasone should be injected intravenously.
(3) Those with respiratory distress are given oxygen inhalation, and tracheotomy is performed for severe laryngeal edema.
(4) Those with circulatory failure are given antishock treatment.
45. What are the causes of hemolytic reaction in blood transfusion? How to deal with it?
Causes:
(1)Input of heterogeneous blood.
(2) Deteriorated blood is imported.
(3) Hemolysis due to Rh factor.
Treatment measures:
(1) Immediately stop blood transfusion and notify the doctor.
(2) Give oxygen inhalation, establish venous access, and give pressure-raising drugs or other medications as prescribed by the doctor.
(3) Send the remaining blood, the patient's blood specimen and urine specimen to the laboratory for testing.
(4) Bilateral lumbar closure and hot compresses with hot water bags were applied to bilateral renal areas to relieve renal tubular spasm and protect the kidneys.
(5) Alkalize the urine: intravenous injection of sodium bicarbonate solution.
(6) Closely observe vital signs and urine output, insert catheter, test hourly urine output and keep record.
(7) If symptoms of shock appear, anti-shock treatment should be carried out.
(8) Psychological care: comfort the patient and eliminate his tension and fear.
46. What are the main contents of condition observation?
(1) General observation: development and body shape, diet and nutritional status, face and expression, position, posture and gait, skin and mucous membranes.
(2) Observation of vital signs.
(3) Observation of state of consciousness.
(4) Observation of pupils.
(5) Observation of the mental state.
(6) Observation of special tests or medication.
(7) Observation of secretions, excretions, and vomit.
47. How to determine different degrees of impaired consciousness?
(1) Drowsiness: the mildest degree of consciousness disorder. The patient is in a persistent state of sleep, but can be awakened by words or mild stimulation, and can answer questions correctly, simply and slowly after waking up, but the response is slow, and the patient falls asleep again soon after stopping the stimulation.
(2) Fuzzy consciousness: its degree is deeper than sleepiness. It is characterized by disorientation, incoherent thinking and speech, delusion, hallucination, restlessness, delirium or psychosis.
(3) lethargy: the patient is in a state of sleep, not easy to wake up. But can be pressed supraorbital nerve, shaking the body and other strong stimulus to wake up, after waking up to answer vague or answer the question, after stopping the stimulation and then into a state of sleep.
(4) Shallow coma: most of the consciousness is lost, there is no voluntary activity, there is no response to light and sound stimulation, and there is a defense reaction such as painful expression or flinching of limbs to pain stimulation.
(5)Deep coma: complete loss of consciousness, no response to various stimuli.
48. How to determine the size of the pupil?
Under natural light, the diameter of the pupil is 2-5mm, with an average of 3-4mm.
Pathologically, the diameter of the pupil is less than 2mm as the pupil is narrowed, and less than Imm as the pinpoint pupil. Pupil diameter greater than 5mm is dilated pupil.
49. What are the clinical manifestations of deep vein thrombosis of the lower extremities? How to prevent it?
Clinical manifestations:
(1) Swelling of the affected limb, accompanied by increased skin temperature.
(2) Localized severe pain or pressure pain.
(3) Positive Humans' sign, with severe pain in the calf on the stomping joint hyperflexion test.
(4) Dilatation of superficial veins.
Preventive measures:
(1) Appropriate exercise to promote venous return. Long-term bedridden and braked patients, to strengthen the bed exercise; postoperative patients early out of bed activities; blood is in a state of hypercoagulability, can be prophylactic application of anticoagulant drugs.
(2) Protection of veins: long-term infusion patients should try to protect the veins, avoid repeated puncture in the same area. Try to avoid venous infusion in the lower limbs.
(3) Quit smoking.
(4) Eat a low-fat, high-fiber diet and keep the bowels clear.
50.What basic principles should be followed in nursing documentation?
(1) Timely: Nursing records must be timely, not delayed or early, not to mention omission,
wrong record to ensure the timeliness of the record. If the rescue failed to record in time, it should be within 6h after the end of the rescue according to the record, and indicate the completion of the rescue and the time to make up the record.
(2) Accuracy: the content is true and error-free, and the time recorded should be the actual time of drug administration, treatment and care.
(3) complete: the eyebrow column, page number must be filled out completely. Records are continuous, no empty since. Sign your full name after each record.
(4) Brief: focused, concise, and fluent, using medical terminology and recognized abbreviations.
(5) Clear: written in red and blue pens respectively as required, with clear handwriting, proper font, kept neat and clean, no alteration, cutting and pasting and misuse of simplified characters
Basic Nursing Knowledge for Nurses2
The basic knowledge that nurses are most basically required to master are the following five:
I. A certain degree of literacy, nursing theory and knowledge of the humanities, as well as participation in nursing education and nursing research. As well as participate in the basic knowledge of nursing education and nursing research. Competent nursing work and the courage to study the business technology to maintain a high level of care.
II. Strong nursing skills and the ability to apply the working methods of the nursing program to solve existing or potential health problems of patients.
Third, with a healthy mind, cheerful, stable emotions, tolerance and open-mindedness, robust physical fitness. Work style is rigorous and subtle, proactive, decisive, agile and pragmatic.
Four, pay attention to civilized manners, standardized terminology, amiable attitude, steady and dignified, neat clothing, generous instrument.
V. Have good medical ethics, integrity and public service. Do not do unlawful operation against moral conscience or disloyal work in order to maintain the reputation of the profession.
Expanded Information:
Nurse's job content:
1, can not violate the rules of operation, labor insurance wear neatly, the implementation of basic and specialized nursing routines, nursing technical operation procedures and related rules and regulations.
2, to assist the doctor to do a good job of consultation, counseling, reception and treatment of patients and their families. Patients should have a high degree of sympathy, considerate and loving, active and enthusiastic, friendly expression, speak gently, work patiently and meticulously, ask questions and answer them, do not argue with the patient.
3, the implementation of medical advice and nursing technical operations. Attention to rounds, observe the condition and infusion, found abnormal timely report to the physician; to assist in the treatment of new, surgical, emergency, critical patients; responsible for blood preparation, blood, escorting critically ill patients out of the examination.
4, regular in-depth ward and patient communication, in order to obtain information about the patient's condition, to understand the patient's concerns, to solve the patient's problems in a timely manner, to give psychological support and humanistic care.
5, strengthen the medical and nursing new knowledge learning, focusing on learning the relevant knowledge of the room. Each patient's condition in the room with medication and treatment is well known, in the treatment and care check, to do a good job. Once the error, can early detection, accurate judgment.
6, responsible for the management of medical documents and goods, do a good job of inventory handover. At the end of the work, do a good job of cleaning and hygiene and pre-preparation for the next day's work, to maintain a clean and beautiful working environment. Timely report, reflect the patient's opinions and requirements of hospital services, and make records.