Two, strictly implement the escort system, strengthen the management of escort personnel, and actively carry out health education and health education. The nurse in charge should introduce the hospitalization rules and hospital rules and regulations to the new inpatients in time, conduct safety education in time, sign the notice of inpatients and educate patients to participate in ward management.
Three, keep the ward clean, comfortable, quiet and safe, avoid noise, talk, walk, operate and close the door lightly.
Four, ward furnishings unified, indoor items and beds should be neatly arranged, fixed position, without the consent of the head nurse shall not be arbitrarily moved.
Five, the staff should abide by labor discipline, stick to their posts. Dress according to regulations during working hours. Smoking is not allowed in the ward, and chatting, sitting around or doing personal things are not allowed during working hours. Personal belongings shall not be stored in the treatment room and nurse station. In principle, personal calls are not accepted during working hours.
Six, the patient's clothing, appliances, according to the base of rationing patients to use, when discharged from the hospital to count back and do terminal processing.
Seven, the head nurse is fully responsible for the custody of ward property and equipment, and assign personnel to manage, establish accounts, and regularly count. If it is lost, find out the reason in time and deal with it according to the regulations. When the management personnel are transferred, the handover procedures should be handled properly.
Eight, hold regular off-duty seminars, listen to patients' opinions on medical care, nursing, medical technology, logistics, etc., deal with problems reflected by patients and give feedback, and constantly improve their work.
Nine, the ward does not receive non-hospitalized patients and does not receive guests. Doctors and nurses on duty should promptly clean up non-chaperones and ask suspicious personnel. It is strictly forbidden to distribute all kinds of leaflets, advertisements and salesmen to enter the ward.
Ten, pay attention to saving water and electricity, turn off the lights and taps on time, and put an end to running water and ever-burning lamps.
Eleven, keep the ward clean, pay attention to ventilation, cleaning at least twice a day, cleaning once a week. Ward bathroom is clean and tasteless. Rescue work system 1. Regularly train nurses in first aid knowledge, improve their awareness and level of rescue, and ensure that when rescuing patients, they are in place, agile, orderly and race against time.
Second, do a clear division of labor during rescue, cooperate closely, obey orders, and stick to their posts.
Three, daily check the rescue items, succession, do account content. All kinds of first-aid drugs, instruments and articles should be "five fixed": fixed variety number, fixed location, designated person management, regular disinfection, sterilization, regular inspection and maintenance. Relief items are not allowed to be arbitrarily misappropriated or borrowed, and must be in a state of emergency. Sterile articles must be marked with sterilization date to ensure their use within the validity period.
Four, to participate in the rescue personnel must master all kinds of rescue techniques and rescue routine, to ensure the smooth progress of the rescue.
Five, closely observe the changes in the condition, accurately and timely fill in the patient care record, the record content is complete and accurate.
Six, strict succession system and inspection system, in the process of rescuing patients, correctly implement the doctor's advice. Oral orders should be accurate and clear, and nurses must repeat them before execution, and then execute them after confirmation; Keep the ampoule for future inspection. Record the nursing record sheet in time, make it up within 6 hours after the rescue, and explain it.
Seven, after the rescue in a timely manner to clean up all kinds of items and preliminary processing, registration.
Eight, conscientiously do a good job in the basic nursing and life nursing of patients. For those who are fidgety, delirious and delirious, add bed bars and take protective restraints to ensure the safety of patients. Prevent and reduce complications. Graded nursing system Graded nursing is based on the priority of patients' illness, and the doctor gives the nursing level in the form of doctor's advice. It is divided into special care, primary care, secondary care and tertiary care.
First, special care
1. Applicable object: patients who are in critical condition and need to be observed and rescued at any time, such as severe trauma, various complicated and difficult operations, organ transplantation, extensive burns, and "five noes" patients.
2. Nursing requirements: (1) assign special personnel to nurse for 24 hours, and closely observe the changes of illness and vital signs; (2) Make a nursing plan, strictly implement various technical operation procedures, implement nursing measures, correctly execute the doctor's advice, and fill in the special nursing record form timely and accurately. (3) Prepare first-aid medicines and equipment for emergencies. (4) Do a good job in basic nursing to prevent complications and ensure the safety of patients. (5) Understand various factors affecting patients' psychological changes, give necessary psychological care and guidance, and conduct health education in time.
Second, primary health care
1. Applicable objects: critically ill patients who are absolutely bedridden, such as after major surgery, shock, paralysis, coma, high fever, hemorrhage, liver and kidney failure and premature infants.
2. Nursing requirements: (1) Visit the patient once every 15-30 minutes, and closely observe the changes of illness and vital signs. (2) Make a nursing plan, strictly implement various diagnosis and treatment and nursing measures, and fill in the nursing record sheet in time. (3) according to the need to prepare rescue drugs and equipment. (4) Do a good job in basic nursing to prevent complications.
Third, secondary health care
1. Applicable objects: patients who are seriously ill and completely unable to take care of themselves, such as those whose condition is stable after major surgery, and patients who are old, weak, young and chronically ill.
2. Nursing requirements: (1) Visit the patient once every 1-2 hours, and pay attention to the condition. (2) Give necessary life help, understand the patient's illness dynamics and psychological state, and meet their physical and mental needs. (3) Give necessary help in life. (4) Record the nursing record sheet on time, and record it in time when the condition changes.
Four or three levels of care
1. Applicable object: mild patients who can basically take care of themselves, such as general chronic diseases, recovery period of diseases, preoperative preparation stage, etc.
2. Nursing requirements: (1) Visit patients twice a day to observe their condition. (2) according to the routine care. (3) urge patients to abide by hospital rules and regulations, and understand patients' condition and psychological dynamic needs. (4) Do a good job in health education.
Nursing handover system 1. Ward nurses implement a 24-hour three-shift rotation duty system, and the duty personnel perform the duties of each shift to care for patients.
Second, the morning meeting will be held collectively every day, and all medical staff will participate, generally not exceeding 15 minutes. The night nurse will report the condition, diagnosis and nursing of critically ill and newly admitted patients in detail. The head nurse makes necessary summary according to the report and briefly arranges the work of the day.
Three, after the succession, led by the head nurse successor * * * cooperate with patrol ward, bedside succession for critically ill patients, postoperative patients, waiting for maternity, postpartum patients, pediatric patients and patients with special circumstances.
Four, the provisions of the handover will be drugs, hemp, drama, restricted drugs and medical equipment, clothing and other face-to-face handover clearly and sign.
Five, in addition to the collective succession every day, each class must be handed over on time. The successor should arrive at the department 10- 15 minutes in advance, count the items to be received, and read the handover report and nursing record sheet. The successor should make clear the patient's condition to the successor, and make bedside handover for critically ill, surgical and pediatric patients and newly admitted patients. The successor shall not leave his post before the handover is clear. Successors should be responsible for any problems caused by unclear handover.
Six, the attendant before the succession in addition to complete the work of the class, need to tidy up the items used, keep the treatment room, nurse station clean, and make the necessary preparations for the next shift.
Seven, the content of the succession
The patient's psychological status, the change of illness, the preparations and precautions for patients undergoing surgery on the same day or the next day and patients undergoing special examinations. The total number of patients, new admission, discharge, operation, delivery, critical illness, death, transfer to other departments (hospitals), first-aid drugs and equipment, special treatment and special specimen collection, etc.
Eight, the method of succession
1. Text handover: write down the nursing record sheet of each shift and change shifts.
2. Bedside handover: patrol the ward with successors, focusing on the handover of critically ill and major surgical patients, elderly patients, pediatric patients and patients with special psychological conditions.
3. Oral handover: Generally, patients take oral handover. Check the system 1. When handling doctor's orders, copy medication cards, injection cards, nursing sheets, etc. , must carefully check the patient's bed number and name, when executing the doctor's advice should indicate the time and sign it. The doctor's order requires BANCHA to check once a day and once a week, and the head nurse will be present and sign. After each inspection, you should register and sign the names of the participants. Two, the implementation and disposal of the doctor's advice should be "three checks, eight pairs. A note. " Three checks: check seven pairs before, during and after operation: bed number, name, drug name, concentration, dosage, usage, time and expiration date. One note: pay attention to adverse drug reactions. Third, under normal circumstances, oral orders are not carried out. Doctors can give oral instructions when rescuing, and nurses must repeat them when executing them, and then execute them after confirming them, and temporarily keep the used empty ampoules. Fill in the doctor's advice in time after the rescue (no more than 6 hours). Four. Blood transfusion: when collecting blood, check with the blood donors in the blood bank. Three checks: the validity period of blood, the quality of blood and whether the blood transfusion device is in good condition; Eight pairs: name, bed number, hospitalization number, bottle (bag) number, blood type, cross-matching test result, blood type and dosage. It can only be retrieved after confirmation, and it will be rechecked by two people according to the above items before blood transfusion. Blood bags should be kept for 12-24 hours after blood transfusion, so that they can be checked correctly when necessary. And stick the barcode on the blood bag on the cross matching report and save it in the medical record. Five, before using drugs, check the drug name, expiration date, batch number and drug quality on the label of the medicine bottle, and do not use it if it does not meet the requirements. After placing the medicine, it must be checked by two people before execution. Six, take all kinds of blood samples into the container, should check the contents of the label again, to ensure that it is correct. Seven, the operation inspection system 1, six check twelve pairs: six check: (1) check when the patient leaves the ward (2) check when the patient enters the operating room (3) check before anesthesia (4) check before skin disinfection (5) check before operation (6) check before and after closing the body cavity. Twelve pairs: subject, bed number, name, gender, age, hospitalization number, operating room number, operation name, operation site, articles and drugs, drug allergy history, whether there is special infection, whether the sterilization instruments and dressings used in the operation are qualified and whether the quantity is consistent. 2, surgical specimens, by the visiting nurses and operators to check and correct the rear can be submitted at the same time with the pathological examination list. 3, surgical specimens in the process of inspection each link strictly handover inspection, and signed by both parties. 8. Supply room checking system 1, when recycling equipment and articles: check the name, quantity, preliminary treatment and integrity of articles. 2. When cleaning and disinfecting: check the effective concentration and preparation concentration of disinfectant; Immersion disinfection time, whether the residual disinfectant is rinsed clean before washing. 3. When packing: check the name, quantity, quality and humidity of instrument dressing. 4. Before sterilization: check whether the packaging specifications of the instrument dressing meet the requirements and whether the installation method is correct; Whether all kinds of instruments and program control of sterilizer meet the standard requirements. 5. After sterilization: Check whether the chemical indicator card of the test package is discolored and damp. Whether biological monitoring is carried out every time the implanted instruments are sterilized. 6. When distributing all kinds of sterilized articles: check the name, quantity, appearance quality, sterilization mark, etc. 7, check the supply room spare all kinds of diagnosis and treatment package is within the validity period, preservation conditions are in line with the requirements. 8. Disposable sterile articles: check batch inspection reports and conduct sampling inspection. 9, timely analysis of nursing defects, find out the reasons and improve. Drug delivery system. Nurses must give drugs in strict accordance with the doctor's advice, and may not change the medicine without authorization. For the problematic doctor's advice, it is necessary to understand clearly before giving medicine to avoid blind execution. Second, understand the patient's condition and treatment purpose, be familiar with the performance, usage, dosage and side effects of various commonly used drugs, and introduce drug knowledge to patients. Three, strictly implement the system of three checks and seven pairs. Three examinations: preoperative, intraoperative and postoperative examinations. Seven pairs: bed number, name, drug name, concentration, dosage, usage and time. Four, before treatment, nurses should wash their hands, wear hats and masks, and strictly abide by the operating procedures. 5. Before taking the medicine, ask the patient if he has a history of drug allergy (if necessary, do an allergy test), explain it to the patient and get cooperation. Pay attention to the drug reaction and treatment effect after taking the medicine, report the adverse reactions to the doctor in time, record the nursing records and fill in the ADR register. Six, when using drugs to check the validity of drugs and whether there is deterioration. Check whether the bottle cap is loose, whether the bottle mouth is cracked, and whether there is precipitation and floc in the liquid. During intravenous infusion. When multiple drugs are used together, we should pay attention to the incompatibility. Seven, the safe and correct use of drugs, reasonable control of the time and method of administration, drugs should be used now, to avoid long-term storage caused by drug pollution or drug efficacy reduction. Eight, after the preliminary cleaning treatment of all kinds of items, by the central supply room recycling. Regular cleaning and disinfection of oral medicine cups for later use. Nine, such as the discovery of medication errors, should be promptly reported, handled, and actively take remedial measures. Do a good job in explaining patients. Nursing rounds system 1. The director of nursing department makes rounds.
1, the director of nursing department takes turns to make rounds at any time every day to check the implementation of nurses' labor discipline, aseptic technique operation and post responsibility system, focusing on critical care, disinfection and isolation, service attitude, etc. , and record the results of the round.
2, specialist nursing rounds once a month, with detailed rounds of results.
3, choose a good difficult cases, critically ill patients or special diseases for rounds. Inform the ward of the contents of rounds in advance, and the head nurse of the ward shall designate the nursing staff who report the cases to make preparations. The medical history, diagnosis, nursing problems, treatment and nursing measures should be briefly reported during rounds, and the rounds should be discussed, and the nursing plan should be revised in time.
4, according to the requirements of nursing work every month, item by item, rounds, strict inspection and evaluation, promote the quality of nursing standards.
Second, the head nurse rounds
1, patrol the ward every morning to check the ward order and the implementation of the post responsibility system for nurses.
2, every two weeks for a specialist nursing rounds, methods with the requirements of the director of the nursing department rounds.
3. Regularly check the writing of nursing forms and the registration of various forms.
Third, the head nurse rounds
1, the head nurse will patrol the ward at any time to check the implementation of nurses' duties, labor discipline and aseptic operation procedures in each class.
2, nursing business rounds once every two weeks, typical cases or critically ill patients at any time, and make a record of rounds.
3, organize teaching rounds, purposefully and in a planned way, according to the teaching requirements, check the typical cases, inform students to be familiar with medical records and patients in advance, organize everyone to discuss with * * * *, or ask questions, and the head nurse will make a summary.
Four, to participate in the doctor's rounds:
The head nurse or responsible nurse in the ward attends the ward rounds of the director or department every week to further understand the condition and the quality of nursing work.
Five, conditional hospitals, the implementation of the director (deputy director) nurses, nurses in charge, nurses three-level business rounds. Patient health education system. Nurses must carry out general health knowledge education and health education for inpatients and outpatients.
Second, the way of health education
1, individual guidance: the content includes general hygiene knowledge, such as personal hygiene, public hygiene, food hygiene, etc. Knowledge of prevention of common diseases, frequently-occurring diseases and seasonal infectious diseases; First aid knowledge, maternal and child health care, infant health care, family planning and other knowledge. When nursing patients, specific guidance should be given in combination with the illness, family situation and life situation.
2. Collective explanation: Outpatients can use the waiting time, and inpatients can use the rest time. Take the form of centralized explanation, demonstration, simulated operation, and playing TV videos.
3. Text publicity: in the form of blackboard newspapers, publicity columns, writing short articles, health education prescriptions, pictures, poems, etc.
Third, health education for patients should run through the whole process of patients seeking medical treatment.
1. Outpatients should have corresponding health knowledge propaganda in registration, triage, diagnosis and treatment.
2, hospitalized patients in the hospital introduction, diagnosis and treatment of nursing process, discharge guidance content should have health knowledge and disease prevention knowledge education. The publicity and education of hospitalized patients should be recorded in the health education registration form, and the effect should be evaluated in time, which should be signed by the responsible nurse and the patient or family members. Nursing consultation system. All complex, difficult or interdisciplinary nursing problems and nursing operation techniques can apply for nursing consultation.
Second, cross-departmental consultation is proposed by the responsible nurse who requires the consultation department, and the head nurse agrees to fill in the consultation application form and send it to the inviting department. The invited department shall complete it within two days after receiving the notice (the emergency consultant shall complete it in time) and write the consultation record.
Three, consultation in the department, put forward by the responsible nurse, presided over by the head nurse or nurse in charge, called the relevant personnel to attend, and make a summary. The responsible nurse is responsible for summarizing the consultation opinions.
Four, to participate in the consultation personnel in principle should be borne by the deputy director of the nurse or above, or by the invited head nurse assigned personnel.
Five, group consultation, organized by the nursing department, the application department nurse in charge is responsible for introducing the patient's condition, and carefully record the consultation situation. General disinfection and isolation management system for wards 1. Patients admitted to the ward should be treated according to infectious diseases and non-infectious diseases, and patients with infectious diseases should be indicated on the patient list card.
Second, the medical staff entering the infected patient's room should strictly implement the disinfection, isolation and protection measures of the corresponding diseases, and wear isolation gown and gloves when necessary. Three, under normal circumstances, the ward should regularly open the window for ventilation, twice a day. Wet wash the ground and disinfect the air if necessary. When obvious pollution is found, it should be disinfected immediately. Terminal disinfection should be carried out after the patient is discharged from hospital, transferred to hospital, transferred to another department and died.
Fourth, the patient's clothes and sheets should be changed once a week. Change it in time when it is contaminated by blood or body fluids, and count the changed clothes and bed unit supplies at the designated place.
Five, medical staff before and after the diagnosis and treatment of different patients, should quickly wash their hands or scrub with hand disinfectant.
Six, all kinds of medical care supplies after use according to the requirements of hospital infection management, patients with special infection use disposable supplies, put them into yellow plastic bags and paste the logo after use, and assign special personnel to be responsible for recycling.
Seven, for patients with special infection to strictly limit the visit and escort personnel, wear isolation pajamas, masks and hats when necessary.
Eight, the patient's tableware, toilet fixed use, special infection of patients' excreta and surplus food, according to the relevant provisions for processing.
Nine, all kinds of medical waste collection, packaging and recycling according to regulations.
Ten, ward and bathroom mops and other sanitary cleaning appliances, to be used separately, and clearly marked. Soak in disinfectant, clean and hang for later use.
Eleven, the patient's bedside table with disinfectant to wipe, make a table with a towel, 1 ~ 2 times a day. The bed is wet and clean, with one towel for each bed, 1 ~ 2 times a day.
Twelve. Key departments: such as operating room, central supply room, delivery room, intensive care unit (ICU, CCU, NICU, etc.), catheter interventional treatment room, endoscope room, dental department, dialysis room, etc. Should meet the disinfection and isolation requirements of the corresponding departments.
Thirteen. The nursing safety management system for special diseases and infected persons meets the relevant requirements 1. Strictly implement various rules and regulations and operating procedures to ensure the normal treatment and nursing work, and the nursing department regularly checks and assesses.
Second, strictly implement the check system, adhere to the doctor's advice class BANCHA, always check every day, the head nurse always check once a week and register and sign.
Three, poisonous, hemp, limited, drama drugs should be used safely, managed by special personnel, stored in the counter and locked. Maintain a fixed base, urge doctors to fill prescriptions in time after use, and hand over registration for each shift.
Four, internal medicine and external medicine are placed separately, and the bottle label is clear.
Five, all kinds of rescue equipment to keep clean and good performance; First-aid drugs meet the requirements, be replenished in time after use, managed by special personnel, counted twice a week and registered; Sterile articles should be clearly marked and stored as required to ensure that they are within the validity period.
Six, the supply room supply all kinds of sterile items can be issued after inspection.
Seven, for what happened in nursing errors, departments should organize discussion in time, and report to the nursing department.
Eight, to strengthen the monitoring and succession of patients with abnormal psychological condition, to prevent accidents.
Nine, in the workplace and ward, it is forbidden for patients to use all kinds of electric stoves, induction cookers, rice cookers and other electrical appliances that are not configured by the hospital to ensure the safety of electricity use.
Ten, formulate and implement emergency plans and emergency care programs for critically ill patients. Nursing error and accident reporting system. All departments should establish a register of errors and accidents, register the process, causes and consequences of errors and accidents, and report them in time.
Second, after an error or accident, active remedial measures should be taken to reduce or eliminate the adverse consequences caused by the error or accident. The head nurse should investigate in time, organize relevant personnel in the department to discuss, analyze and identify the reasons, sum up experiences and lessons, and make detailed records.
Three, the units and individuals that make mistakes and accidents and intentionally conceal them shall be dealt with according to the seriousness of the case.
Four, nursing department should regularly organize the head nurse to analyze the causes of errors and accidents, and put forward preventive measures. Preoperative patient visiting system 1. In order to let the patients cooperate with the medical staff to complete the operation smoothly, the nurses in the operating room must visit the patients undergoing elective surgery 1 day before operation. Read the medical records to understand the general information of patients (name, gender, age, nationality, weight, education level, etc.). ), and collect the patient's clinical data (preoperative diagnosis, surgical name, surgical approach, various examination results; Whether there is special infection, blood type matching, allergic history and surgical history. ).
Second, understand the patient's psychological state and carry out necessary psychological counseling and nursing.
Third, do a good job in preoperative education:
1, explaining the relevant precautions to patients, such as fasting, drinking water, not wearing makeup, removing accessories, dentures, changing surgical gowns and pants, etc.
2. Introduce the coordination method and importance of operation and anesthesia posture. 3. Introduce the operating room environment and operation precautions.
Fourth, humanistic care should be reflected in the visit. Nurses should be enthusiastic, introduce themselves actively, patiently answer patients' questions, and alleviate or eliminate patients' doubts and fears. Pay attention to protecting patients' privacy, make necessary information according to the situation, and conscientiously implement the protective medical system.
Five, visit content should be carefully recorded in the surgical nursing records.