基础护理操作流程(34页).doc

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1、- 基础护理操作流程供护理本科使用编者：沈军 2008年3月目录卧床病人更换床单法3静脉输液5备用床6麻醉床7大量不保留灌肠8静脉取血9口腔护理10穿脱隔离衣11皮内注射与皮试液的配制12肌肉注射法13皮下注射法14手术室刷手规则15无菌技术操作16女病人导尿术17心肺复苏抢救护理程序18心肺复苏术19Replace Bedsheet with a Patient in20Intravenous Infusion 21Prepare Standby Bed 22Prepare Anesthesia Bed 23Enema24Intravenous Phlebotomizing 25Oral C

2、avity Nursing 26Put on and Take off the Barrier Gown 27Hypodermic Injection and Drug Solution Preparation for Skin Tes t 28Intramuscular Injection29Hypodermic Injection 30Hand Washing Principles in Surgery31Aseptic Techniques32Urethral Cathererization on Female Patient 33CPR Nursing Process in Emerg

3、ency 34前 言护理学基础课程，是护理专业学生的基础课程，也是护理专业学生的主干课程。是护理专业的重点课程，主干学科。其主要任务是使学生获得和掌握护理病人员所必须的基本理论、基本知识、基本技能。实验课是培养学生护理技能的重要环节，通过实验课学习和强化操练，培养学生良好的职业素质，较强的护理实践技能、敏锐的观察、分析和判断问题的能力。为后期其他护理专业课程的学习及临床护理打下坚实的基础。在此我们根据姜安丽主编的“十一五”国家级规划教材新编护理学基础的内容，结合任课教师上课了解到的学生实际情况编写了这本护理学基础操作流程图。本书在编写、审定过程中，得到重庆医科大学护理学院的领导和专家的热情指导

4、和关怀，在此表示衷心的感谢！限于水平有限，书中难免会有一些疏漏和不成熟之处，敬请广大读者批评指正。 编者 2008年3月卧床病人更换床单法用物准备枕套、大单、中单、被套、带套床刷解释移椅用物置于护理车上至床旁携物至床前放松床尾被套、带套床刷站床右侧协助病人左侧卧位松开右侧橡胶单、中单及底单协助病人平卧站床左侧平卧薪尝卧薪尝中单向上卷至病人身下扫橡胶单按内折法将棉胎拆成S型橡胶单搭于病人身上卷大单于病人身下清洁被套铺于棉被上更换大单及中单扫床褥铺大单对侧向上卷于身下取出棉胎，套入清洁被套内床头、床尾铺角塞大单中间部分于床垫下按S型法整理棉被取出污被套将左右两侧齐床沿做成被筒，整理床尾更换被套铺平

5、橡胶单及中单塞入床垫下助病人翻身至右侧至床左侧棉被尾端内折平床垫协助病人取舒适卧位更换枕套取下污中单扫橡胶单搭于病人身上取下污大单于护理车下层扫床褥依次铺好移回桌椅静脉输液注射盘、药物、输液器、止血带、小垫枕、输液贴、输液架床刷用物准备核对解释询问是否排便初选静脉被套、带套床刷移输液架至床前检查药物消毒瓶塞检查输液器准备药物连接输液器关闭调节器开关挂输液瓶排气放止血带、小垫枕嘱握拳穿刺输液前准备扎止血带消毒皮肤再次排气见回血再进少许松止血带松拳松调节器穿刺（通畅后）固定调节滴速观察记录取下止血带、小垫枕协助病人取舒适卧位、交待注意事项操作后整理整理床单位分类处理污物巡视观察备用床（被套法）用物

6、准备大单、被套、枕套、被褥、枕芯于床尾移开床旁桌携物至床前移椅至床尾置用物于椅上被套、带套床刷翻转棉褥、床垫并清洁依次铺好床右侧打开床头、床尾分别铺角铺大单塞入中间部分至对侧依次铺好床左侧打开至床尾铺被套套被套至床尾系带将被盖向内齐床沿做成被筒套被套在椅面上操作同法铺好右侧棉被尾端折叠于床垫下至床右侧枕头开口背门放平套枕套移回床旁桌、椅查看床单位麻醉床（被套法）大单、被套、枕套、橡皮单2、中单2、麻醉盘、带套床刷用物准备移开床旁桌携物至床前移椅至床尾置用物于椅上床右侧铺单床头、床尾分别铺角翻转床褥、床垫并清洁依次铺好平卧薪尝卧薪尝塞入中间部分床右侧铺橡胶单距床头45-50cm铺床上铺中单同塞入

7、床垫下另一橡胶单、中单齐床头并塞入床垫下铺被套至床对侧依次铺好床左侧打开至床尾套被套套被套至床尾系带下移棉被15cm内两侧内折成被筒尾端内折平床尾在椅面上操作套枕套至床右侧开口背门横立于床头三折棉被于床一侧开口对门移回床旁桌椅置麻醉盘于桌上移椅于棉被一侧床尾大量不保留灌肠治疗盘：灌肠筒、弯盘、肛管、手纸、棉签、凡士林、橡皮单、巾、一次性塑料手套一双用物准备配液用物：大小量杯、热、凉水、水温计、纱布、1-2%肥皂水或NS取1-2%肥皂液或NS500-1000ml倒入灌肠筒中配液屏风便器测量水温（39-41）治疗盘放桌上移椅放便器携物至床前挂灌肠筒于输液架上（距肛门40-60cm）润滑肛管核对解释

8、关门窗档围屏灌肠前准备协助病左侧位臀齐床沿排气，暴露肛门插管7-10cm脱裤至臀下垫橡皮单、巾一手固定肛管，一手开放管夹嘱病人深呼吸灌肠取下肛管放于消毒液中浸泡消毒嘱病人忍耐5-10分钟给便器或自解操作后整理完毕夹管放下灌肠筒取手纸拔肛管去橡皮单、巾整理床单位去围屏开窗静脉取血注射盘、注射器、针头、止血带、小垫枕、盛血容器用物准备携物至床前核对解释平卧薪尝卧薪尝放小垫枕止血带初选静脉取血前准备准备并检查注射器、针头系止血带消毒皮肤嘱握拳穿刺根据目的决定取血量取血嘱松拳松止血带拔针按压取下止血带、小垫枕整理床单位分类处理污物操作后整理标本送验口腔护理清洁盘：治疗碗、镊子、止血钳、盐水棉球、弯盘、

9、压舌板、吸水管、纱布盘外：手电、石蜡油、棉签、漱口液携物至床前检查口腔、擦拭口唇擦洗牙外面内面咬合面颊部(由里向外)(先上后下)上腭舌面舌下漱口检查操作后整理擦试口腔用物准备 注:每次擦拭只夹一个棉球,由内向外擦.穿脱隔离衣衣架、隔离衣、手刷、避污纸、治疗碗内盛肥皂液用物准备个人准备戴口罩摘手表卷袖过肘被套、带套床刷手持衣领（清洁面向自己）穿隔离衣穿袖举双手抖袖系领系袖解腰带打活结解袖内塞于肘下系腰带操作冲双手刷前臂手背手掌刷手手指指甲冲净擦干解领退袖脱隔离衣脱下对齐清洁面向外挂于半污染区皮内注射与皮试液配制用物准备治疗盘内：注射卡，1ml、5ml注射器、针头消毒液、棉签、药物、生理盐水、启瓶

10、器、0.1%盐酸肾上腺素、弯盘操作者准备分别准备药物溶药前准备注入气体2ml吸生理盐水2ml去除铝盖中间部分分别消毒瓶盖溶药注入“青霉素”密封瓶摇匀检查1ml注射器、换上6号针头消毒瓶塞吸青霉素0.1ml配制吸生理盐水0.9ml核对解释询问“三史”选部位洒精消毒皮肤摇均匀弃去0.9ml,排于弯盘内，剩0.1ml注射前排气绷紧皮肤稀释三次，排去二次注射配好皮试液1ml，换上4号针头手持注射器针尖斜面与皮肤呈5角刺入注入0.1ml出现皮丘再次核对整理床单位说明注意事项拔针20min后观察结果操作后整理分类处理污物肌肉注射注射治疗盘内：注射卡，药物、5ml注射器及针头、消毒液、棉扦、弯盘吸药携物至床

11、前注射前准备用物准备操作者准备核对医嘱检查药物消毒安瓿或瓶塞消毒小锯折断安瓿颈部检查注射器及针头核对、解释备好体位选择部位消毒皮肤排尽气体吸药液绷紧局部皮肤垂直进针抽视无回血缓慢注药液干棉签轻压拔针按压观察再次查对整理床单位分类处理污物手持注射器操作后整理吸药前准备皮下注射法用物准备治疗盘内：注射卡，药物、2ml注射器及针头、消毒液、棉签、弯盘操作者准备核对医嘱检查药物消毒安瓿吸药前准备折断安瓿颈部吸药液检查注射器及针头吸药手持注射器核对、解释备好体位选择部位消毒皮肤注射前准备绷紧局部皮肤与皮肤呈3040排尽气体注射进针抽视无回血注射药液整理床单位干棉签轻压拔针按压观察再次查对操作后整理分类处

12、理污物手术室刷手规则 刷手前要修剪指甲，并用肥皂水洗去手、前臂、肘及上臂下半部污垢及油脂。 1取无菌刷蘸取洗手液，按下列顺序刷洗，不可遗漏：指甲手指掌心手背腕部前臂肘上三寸。（注意甲缘、指缝、腕横纹、肘窝处） 2第一遍刷完后，用流动水冲掉洗手液，手指朝上肘朝下，水由前臂到肘部流下，手在高位，以免水逆流。 3第三遍刷完后用无菌毛巾拭干手、臂、不得擦至肘上三寸。洗完毕后，手臂不能下垂，应在胸前保持拱手姿势。不可触及未消毒的物品，否则重新刷手。 4刷手时间10分钟，共刷3遍。无菌技术操作用物准备无菌物品：持物钳、容器、治疗碗、治疗巾、手套、溶液、方盒、无菌包、浸泡罐清洁物品：中号治疗盘、弯盘、笔、纸

13、清洁操作台清洁治疗盘操作前准备剪指甲洗手被套、带套床刷检查无菌包解带缠好将无菌治疗碗取放于无菌盘内铺无菌盘开包夹取治疗巾按原折痕包好记录开包时间、日期核对瓶签检查溶液按无菌方法打开溶液瓶塞扇形打开治疗巾，开口向外倒无菌溶液冲瓶口倒液于无菌治疗碗内夹取所需无菌用物于盘内按无菌方法盖瓶塞记录开瓶时间、日期盖好治疗盘对齐边缘盖无菌盘将开口处向上折叠两次左、右两侧向下折叠各一次记录铺盘有效时间检查抓取袋口取一只手套反折部分戴好戴无菌手套脱无菌手套抓取袋口插入另一只手套反折内面反转脱下手套置污物袋内戴好冲洗滑湿粉女病人导尿术无菌导尿包：治疗碗2、止血钳1、镊子1、导尿管2、消毒液棉球数个、小杯、石蜡油棉

14、签、弯盘、孔巾。用物准备擦洗用物：无菌治疗碗内盛消毒液棉球、弯盘、镊子、手套、浴巾。解释关门窗遮挡携物至床前松床尾盖被仰卧屈膝位双腿分开脱对侧裤与浴巾盖近侧腿上盖被包对侧腿露出外阴操作前准备橡胶单、巾垫臀下弯盘置外阴前左手戴手套或指套消毒液棉球分别擦洗外阴阴阜大阴唇小阴唇尿道口肛门消毒液擦洗外阴无菌盘至两腿之间，打开无菌导尿包污棉球放弯盘将治疗碗及弯置于床尾带手套铺孔巾润滑尿管夹出一根尿管备用左手分开小阴唇去孔巾擦外阴导尿消毒尿道口对侧小阴唇近侧小阴唇再消毒尿道口脱手套移去治疗盘及橡胶单、巾协助穿裤整理床单位操作后整理右手持止血钳夹尿管轻插4-6cm整理用物记录送标本见尿后再插入尿管1cm放前

15、段尿协助留无菌中段尿标本拔出尿管放弯盘内心肺复苏抢救护理程序一、 评估 1主要依据：意识突然丧失，大动脉博动消失。 2其他依据：心音消失，血压测不到，叹息样呼吸，随即停止，瞳孔散大，紫绀。二、抢救程序：心肺复苏术（另附）三、效果评价1有效：能摸到大动脉博动，出现自主呼吸，意识逐渐恢复，瞳孔由大变小，对光反应恢复。2无效：不能摸到大动脉搏动，瞳孔散大，无自主呼吸。四、注意事项 1进行心肺复苏时，动作要迅速、准确，吹气时暂时停止按压胸部，按压用力要均匀，双手注意不要离开病人胸部。 2复苏成功后，及时给予病人家属心理支持，做好必要的解释工作。心 肺 复 苏 术 cardio pulmonary re

16、suscitation,CPR 呼救并请人通知医生 开放气道 将病人去枕平卧，置于硬板床上或背部垫心脏按摩板 将病人头偏向一侧，清除呼吸道分泌物 用仰头一抬颏法或托下颌法打开气道 基本生命支持 BLS 人工呼吸： 立即进行人工呼吸，第一次吹气时，吹两次 （吹气量：400600ml/次） 人工循环： 进行胸外心脏按压 按压部位 胸骨下半部（按压部位胸骨中下1/3处） 按压频率 100次/min 按压深度 成人45cm；513岁儿童3cm； 按压与人工呼吸比：30:2 进一步维持气道通畅，协助医生进行气管插管，用简易呼吸囊或呼吸机辅助呼吸 必要时进行直流电非同步除颤 进一步生命支持 心电监护，密切

17、监测患者的生命体征 ALS 建立静脉通道，必要时进行深静脉穿刺，遵医嘱合理使用药物如肾上腺素、利多卡因、阿托品、碳酸氢钠等 尽快纠正脑缺氧，呼吸机给予机械通气 长期生命支持 予高压氧治疗及低温疗法，一般保持正常体温 PLS 遵医嘱应用脱水剂、利尿剂、糖皮质激素改善脑代谢促进剂 维持水电解质及酸碱平衡 详细记录抢救经过Replace Bedsheet with a Patient inPillowcase, bottom sheet, middle-bed sheet, quiltcover, covered bed brushPrepare articlesInterpret; move aw

18、ay the chair; place articles onto the nursing cart; move the cart to bedTake aticlesto bedLower the bed end被套、带套床刷Stand on the right; Roll the patient to lie on left sideLose the plastic, mid-bed and bottom sheet from the rightStand on the lfet and assit patient to lie on back平卧薪尝卧薪尝Roll the mid-bed

19、 sheet to the patient; brush the plastic sheetFold inward the badding to a shape SLift the plastic sheet on the patient; roll over the bottom sheet to the patientPlace a clean cover on the quiltReplce the bottom and mid-bed sheetBrush the mattress; bespread a clean bottom sheet with the left under t

20、he patientInsert the badding into the clean coverNeaten the quilt into S; take off the soiled coverWrap the four coners; tuck the middle unwanted part under the mattressShape quilt into a tube along the bed two sides; smooth the bed endChange the quilt coverPlace back the plastic and mid-sheet; tuck

21、 the unwanted part under the mattressRoll the patient to the other sideFold inward quilt end aligning mattressTake off the soiled mid-sheet; brush the plastic sheet and lift on the patientAssist patient to be in a cosy positionChange pillowcasTake off the soiled bottom sheet to the lower shelf of th

22、e nursing cart; brush the mattress; bespread sheets in orderMove back table and chairIntravenous InfusionTray, drugs, apparatus, tourniquet, bolster, fixative bandage, apparatus holderPrepare articlesCheck ?interpretMove holder to bedInquire upon defecation ? select vein 被套、带套床刷CheckSterilize bottle

23、 closure; check apparatusPrepare drugsJoin apparatuses; shut off the regulatorHang bottle on holder ?vent air in passwayPut tourniquet and bolster in placeAsk patient to clench fist; insertPrepare for infusionBind tourniquet ? sterilize skin? vent air againInsert a liitle more while blood present in

24、 the passawayInsert the needleFix apparatus on after being dropsPlace bake tourniquet and bolster ? assist patient to be in a cosy position; explain dos and dontsRegulate drops; observe; documentTidy up after operationSmooth bed sheets ?dispose the soiled matters ?observe the patient and the dropsPr

25、epare Standby BedPrepare articlesBottom sheet, quiltcover, pillowcase badding, and pillow dMove away the bedside tableTake articles to bedMove the chair to bed end; place articles on the chair被套、带套床刷Turn over and clean mattress and pad; place back in orderBespread right part of bottom sheet; wrap tw

26、o cornersBespread bottom sheetTuck the middle unwanted part; bespread the left sideBespread left side to the bed endBespread quilt coverSlip on cover to the two ends; tie upShape cover into tube-shape along the bed two sidesSlip on quilt coverBespread right side; tuck the two ends under the padPerfo

27、rm on the chairStand on right side of the bed; place the pillow on bed backward the wards doorSlip on pillocaseMove back the bedside table and chair; check the bed sheetsPrepare Anesthesia BedBottom sheet, quiltcover, pillowcase, two plastic sheets, two mid-sheets, anesthesia tray, covered bed brush

28、Prepare articlesMove away the bedside tableTake articles to bedBespread the right part of the bottom sheet; wrap the two cornersMove chair to bed end; place articles on chairTurn over and clean mattess ad pad; place back in order平卧薪尝卧薪尝Tuck the middle unwanted partMake bedBespread the plastic sheet

29、45-50cm off the bed head on the rightBespread mid-sheet; tuck the unwanted part under padBespread the other plastic sheet and mid-sheet over bed head; tuck unwanted part under the padBespread quilt coverBespread the other side in same orderBespread the left side to the bed endSlip on the cover to be

30、d end; tie upPull down the quilt 15cm; fold inward the two sides into tube-shape; fold inward the quilt end along the bed endSlip on quilt coverFold up 3 times with opening towards the doorPerform on the chairPlace pillow erect on the bed head towards the wards doorSlip on pillowcaseMove back the be

31、dside table and chair; place the anesthesia tray on the table; move the chair to the bed end on the side with the quiltEnemaIn the tray: enema bucket, kidneybasin, anal tube, bumf, cotton swab, Vaseline, rubber sheet, rubber napkin, disposable rubber glovePrepare articlesPour 1- 2% soap solution or

32、500- 100ml NS into the enema bucketArticles for preparing the solution: large and smaller measuring cups, warm and cool water, water temperature gauge, gauze, 1- 2%soap solution or NSPrepare enema solutionTest the water temperatureFolding screen, evacution containerTake articles to bedPlace the tray

33、 on the table and the evacuation container on the chairHang enema bucket on the infusion holder (40-60cm to the anal); lubricate the anal tubeCheck; interpret; close the window and door; unfold the screenPrepare for enemaVent air from the tube; expose the anal; insert the tube 7-10cm into the analAs

34、sist the patient to lie on the left side with the hip along the bed edgePull the trousers down to the buttock; bespread the rubber sheet and napkin Hold the anal in one hand and the other open the clampEnemaImmerse the anal tube in the antiseptic solutionRequire the patient to take deep breathTidy u

35、p after the operationDemand the patient to hold on for 5-10 minutes and then evacuate into the container or in the toiletFinish enema; clip on the clamp; ？take down the enema bucketGet some bumf;？ pull out the ananl tubeTake off the rubber sheet and napkin; smooth the bed sheets; fold up the screen;

36、 open the window and doorIntravenous PhlebotomizingInjection tray, syringe, hypodermic needle, tourniquet, bolster, blood containerPrepare articlesTake articles to bedCheck ？interpret平卧薪尝卧薪尝Place the bolster, ？ tourniquet and choose the vein in placePrepare to draw bloodGet and check the syringe and needleFasten the tourniquet; ？ sterilize the skinRequire patient to cl