口腔?？谱o理操作流程考核評分標準

/r/n口腔專科護理技術(shù)操作考核要點及評分標準目錄/r/n第一項/r/n/r/n一般洗手操作/r/n實施/r/n要點及評分標準/r/n…………………/r/n…/r/n./r/n5/r/n第二項/r/n/r/n無菌技術(shù)操作考核要點及評分標準/r/n……………………/r/n./r/n7/r/n第三項/r/n/r/n生命體征監(jiān)測技術(shù)操作考核要點及評分標準/r/n................................/r/n./r/n10/r/n第四項/r/n/r/n/r/n口腔護理技術(shù)操作考核要點及評分標準/r/n………………/r/n./r/n14/r/n第五項/r/n/r/n鼻飼技術(shù)操作考核要點及評分標準/r/n……………………/r/n./r/n16/r/n第六項/r/n/r/n女病人導尿技術(shù)操作考核要點及評分標準/r/n……………/r/n./r/n18/r/n第七項/r/n/r/n鼻塞〔鼻導管〕吸氧技術(shù)操作考核要點及評分標準/r/n…………………/r/n./r/n20/r/n第八項/r/n/r/n換藥技術(shù)操作考核要點及評分標準/r/n……………………/r/n./r/n22/r/n第九項/r/n/r/n霧化吸入技術(shù)操作考核要點及評分標準/r/n………………/r/n./r/n2/r/n4/r/n第十項/r/n/r/n口服給藥技術(shù)操作考核要點及評分標準/r/n………………/r/n./r/n26/r/n第十一項密閉式輸液技術(shù)操作要點及評分標準/r/n/r/n………………/r/n./r/n28/r/n第十二項密閉式靜脈輸血技術(shù)操作要點及考核評分標準/r/n………/r/n30/r/n第十三項靜脈留置針技術(shù)考核要點及評分標準/r/n…………………/r/n32/r/n第十四項靜脈采集血標本技術(shù)操作要點及考核評分標準/r/n………/r/n34/r/n第十五項靜脈注射技術(shù)操作考核要點及評分標準/r/n………………/r/n36/r/n第十六項動脈血標本的采集技術(shù)操作考核要點及評分標準/r/n……/r/n38/r/n第十七項肌內(nèi)注射技術(shù)操作考核要點及評分標準/r/n………………/r/n40/r/n第十八項皮內(nèi)注射技術(shù)操作考核要點及評分標準/r/n………………/r/n42/r/n第十九項皮下注射技術(shù)操作考核要點及評分標準/r/n………………/r/n44/r/n第二十項酒精拭浴降溫技術(shù)操作考核要點及評分標準/r/n…………/r/n46/r/n第二十一項心肺復蘇技術(shù)操作考核要點及評分標準/r/n………………/r/n48/r/n第二十二項經(jīng)鼻/口腔吸痰法技術(shù)操作考核要點及評分標準/r/n……/r/n./r/n5/r/n0/r/n第二十三項/r/n氣管切開〔呼吸機〕病人吸痰技術(shù)操作考核要點及評分標準/r/n………/r/n5/r/n2/r/n第二十四項心電監(jiān)測技術(shù)操作考核要點及評分標準/r/n………………/r/n5/r/n4/r/n第二十五項輸液泵／微量輸注泵的使用技術(shù)考核要點及評分標準/r/n………………/r/n5/r/n6/r/n第二十六項血氧飽和度監(jiān)測技術(shù)/r/n……………………/r/n./r/n5/r/n8/r/n第二十/r/n七/r/n項除顫技術(shù)操作考核要點及評分標準/r/n........................................./r/n6/r/n0/r/n第二十/r/n八/r/n項軸線翻身法技術(shù)操作考核要點及評分標準/r/n……………/r/n./r/n6/r/n2/r/n第二十/r/n九/r/n項患者搬運法技術(shù)操作考核要點及評分標準/r/n……………/r/n./r/n6/r/n4/r/n第/r/n三十/r/n項/r/n/r/n病人保護性約束技術(shù)操作考核要點及評分標準/r/n…………/r/n./r/n6/r/n8/r/n第三十/r/n一/r/n項/r/n痰標本采集法技術(shù)考核要點及評分標準/r/n………………/r/n./r/n7/r/n0/r/n第三十/r/n二/r/n項咽拭子標本采集法技術(shù)操作考核要點及評分標準/r/n……/r/n./r/n7/r/n2/r/n第三十/r/n三/r/n項病人出入院操作考核要點及評分標準/r/n…………………/r/n./r/n7/r/n4/r/n第三十/r/n四/r/n項患者跌倒的預防技術(shù)操作考核要點及評分標準/r/n………/r/n./r/n7/r/n6/r/n第三十/r/n五/r/n項壓瘡的預防及護理技術(shù)操作考核要點及評分標準/r/n……/r/n./r/n7/r/n8/r/n第三十/r/n六/r/n項磷酸鋅粘固粉調(diào)和技術(shù)操作考核要點及評分標準/r/n……/r/n./r/n8/r/n1/r/n第三十/r/n七/r/n項玻璃離子水門汀充填術(shù)配合法要點及評分標準/r/n………/r/n./r/n8/r/n3/r/n第三十/r/n八/r/n項/r/n調(diào)取上下頜印模(藻酸鹽印模材)/r/n要點及/r/n評分標準/r/n…………………/r/n../r/n86/r/n第三十/r/n九/r/n項/r/n/r/n光敏修復術(shù)配合法/r/n要點及/r/n評分標準/r/n……………………/r/n./r/n8/r/n8/r/n第/r/n四十/r/n項/r/n/r/n下頜阻生齒拔除術(shù)配合與擊錘法/r/n要點及/r/n評分標準/r/n……/r/n./r/n90/r/n第四十/r/n一/r/n項/r/n頜面手術(shù)后氣管切開傷口換藥技術(shù)操作考核/r/n要點及/r/n評分標準/r/n………/r/n./r/n92/r/n第四十/r/n二/r/n項/r/n口腔頜面?zhèn)谪搲阂骷夹g(shù)操作考核/r/n要點及/r/n評分標準/r/n………………/r/n./r/n95/r/n第四十/r/n三/r/n項/r/n口腔沖洗技術(shù)操作考核/r/n要點及/r/n評分標準/r/n………………/r/n./r/n97/r/n第四十/r/n四/r/n項/r/n牙周塞治劑調(diào)拌技術(shù)考核/r/n要點及/r/n評分標準/r/n……………/r/n./r/n99/r/n第四十/r/n五/r/n項/r/n四手操作技術(shù)考核/r/n要點及/r/n評分標準/r/n……………………/r/n./r/n1/r/n0/r/n0/r/n第四十六項根管充填劑調(diào)和技術(shù)/r/n評分標準/r/n〔1〕/r/n…………………/r/n…/r/n10/r/n2/r/n第四十七項根管充填劑調(diào)和技術(shù)/r/n評分標準/r/n〔2〕/r/n……………………/r/n104/r/n第四十八項窩溝封閉術(shù)護理配合的評分標準/r/n………/r/n../r/n106/r/n護士工作、操作流程/r/n……………………/r/n………………/r/n108/r/n健康教育工作流程/r/n…………………/r/n………/r/n…/r/n………………/r/n108/r/n病房護士長工作流程/r/n……………………/r/n……/r/n109/r/n晨會交班流程/r/n…………………/r/n110/r/n/r/n/r/n護士床頭交接班流程/r/n………………………/r/n./r/n./r/n111/r/n病區(qū)責任護士工作流程/r/n…/r/n……………………/r/n……………/r/n./r/n./r/n112/r/n辦公室護士工作流程/r/n…………/r/n……………/r/n./r/n./r/n113/r/n夜班護士工作流程/r/n……………/r/n………………/r/n114/r/n護士輸液操作流程/r/n……………/r/n………………/r/n115/r/n輸液反響處理流程/r/n……………/r/n116/r/n護士執(zhí)行醫(yī)囑流程/r/n……………/r/n117/r/n/r/n護士核對醫(yī)囑流程/r/n…………/r/n./r/n118/r/n/r/n配合科主任、主治醫(yī)生查房流程/r/n……………/r/n……………/r/n./r/n119/r/n/r/n護理教學查房流程/r/n…………/r/n./r/n120/r/n/r/n臨床操作帶教流程/r/n……………/r/n……………/r/n./r/n121/r/n/r/n護理臨床小講課流程/r/n………………………/r/n./r/n122/r/n/r/n病人投訴接待流程/r/n…………/r/n./r/n123/r/n/r/n術(shù)前病人護理流程/r/n…………/r/n./r/n124/r/n/r/n術(shù)后病人護理流程/r/n…………./r/n125/r/n/r/n過敏試驗操作流程/r/n…………/r/n./r/n126/r/n/r/n青霉素過敏性休克搶救流程/r/n………………/r/n./r/n127/r/n/r/n新藥給藥流程/r/n……………/r/n./r/n128/r/n/r/n靜脈留置針操作流程/r/n……………………/r/n./r/n129/r/n/r/n輸血操作流程/r/n……………/r/n./r/n130/r/n/r/n霧化吸入操作流程/r/n…………………...../r/n............/r/n131/r/n/r/n氣管插管配合流程/r/n………………………/r/n./r/n132/r/n/r/n機械通氣配合流程/r/n………………………/r/n./r/n133/r/n/r/n中心靜脈壓測定流程/r/n……………………/r/n./r/n134/r/n/r/n心電監(jiān)護流程/r/n……………/r/n./r/n135/r/n/r/n電除顫配合搶救流程/r/n……………………/r/n./r/n136/r/n/r/n氣管切開術(shù)配合搶救流程/r/n………………/r/n./r/n137/r/n/r/n留置導尿護理流程/r/n……………………/r/n138/r/n/r/n壓瘡護理流程/r/n…………/r/n139/r/n/r/n死亡病人處理流程/r/n……………………/r/n140/r/n/r/n終末處理流程/r/n…………/r/n141/r/n/r/n門診護士長工作流程/r/n…………………/r/n142/r/n/r/n門診護士工作流程/r/n……………………/r/n143/r/n/r/n導診護士工作流程/r/n……………………/r/n144/r/n/r/n采血室護士工作流程/r/n…………………/r/n145/r/n/r/n急診分診護士工作流程/r/n………………/r/n146/r/n/r/n急診搶救室護士工作流程/r/n……………/r/n147/r/n/r/n急診搶救工作流程/r/n……………………/r/n148/r/n/r/n急診留觀室護士工作流程/r/n……………/r/n149/r/n/r/n急診輸液工作流程/r/n……………………/r/n150/r/n一、手衛(wèi)生/r/n一般洗手/r/n〔一〕目的/r/n：/r/n去除手部皮膚污垢、碎屑和局部致病菌。/r/n〔二〕實施要點/r/n1.洗手指征：/r/n(1)直接接觸患者前后。/r/n(2)無菌操作前后。/r/n(3)處理清潔或者無菌物品之前。/r/n(4)穿脫隔離衣前后，摘手套后。/r/n(5)接觸不同患者之間或者從患者身體的污染部位移動到清潔部位時。/r/n(6)處理污染物品后。/r/n(7)接觸患者的血液、體液、分泌物、排泄物、粘膜皮膚或者傷口敷料后。/r/n2.洗手要點：/r/n(1)正確應用六步洗手法，清洗雙手，也可以將洗手分為七步，即增加清洗手腕。/r/n(2)流動水下徹底沖洗，然后用一次性紙巾/毛巾徹底擦干，或者用干枯燥雙手。/r/n(3)如水龍頭為手擰式開關(guān)，那么應采用防止手部再污染的方法關(guān)閉水龍頭。/r/n〔三〕考前須知/r/n1.認真清洗指甲、指尖、指縫和指關(guān)節(jié)等易污染的部位。/r/n2.手部不佩帶戒指等飾物。/r/n3.應當使用一次性紙巾或者干凈的小毛巾擦干雙手，毛巾應當一用一消毒。/r/n4.手未受到患者血液、體液等物質(zhì)明顯污染時，可以使用速干手消毒劑消毒雙手代替洗手。/r/n外科手消毒/r/n〔一〕目的/r/n：/r/n1.去除指甲、手、前臂的污物和暫居菌。2.將常居菌減少到最低程度。/r/n3.抑制微生物的快速再生。/r/n〔二〕實施要點/r/n1.外科手消毒指征：進行外科手術(shù)或者其他按外科手術(shù)洗手要求的操作之前。/r/n2.操作要點：/r/n(1)修剪指甲、銼平甲緣，去除指甲下的污垢。(2)流動水沖洗雙手、前臂和上臂下1/3。/r/n(3)取適量皂液或者其他清洗劑按六步洗手法清洗雙手、前臂和上臂下1/3，用無菌巾擦干。/r/n(4)取適量手消毒劑按六步洗手法揉搓雙手、前臂和上臂下1/3，至消毒劑枯燥。/r/n〔三〕考前須知/r/n1.沖洗雙手時，防止水濺濕衣褲。/r/n2.保持手指朝上，將雙手懸空舉在胸前，使水由指尖流向肘部，防止倒流。/r/n3.使用后的海棉、刷子等，應當放到指定的容器中，一用一消毒。/r/n4.手部皮膚無破損。5.手部不佩帶戒指、手鐲等飾物。/r/n第一項/r/n一般洗手操作考核評分標準/r/n單位及科室：被考核人：主考教師：/r/n考核日期：/r/n/r/n/r/n/r/n/r/n項目/r/n總/r/n分/r/n評分細那么/r/n評分等級/r/nA/r/nB/r/nC/r/nD/r/n儀表/r/n5/r/n儀表端莊，服裝整潔/r/n5/r/n4/r/n3/r/n2/r/n溝通技巧/r/n10/r/n表情自然，語言親切、流暢、通俗易懂,/r/n能完整表達護理要求./r/n10/r/n8/r/n6/r/n4/r/n評估/r/n10/r/n10/r/n8/r/n6/r/n4/r/n操作前準備/r/n5/r/n環(huán)境清潔/r/n無長指甲/r/n1/r/n2/r/n2/r/n0/r/n1/r/n1/r/n0/r/n1/r/n1/r/n0/r/n0/r/n0/r/n操作過程/r/n方法正確/r/n70分/r/n1.掌心相對，手指并攏，相互揉搓/r/n2.手心對手背沿指縫相互揉搓/r/n3.掌心相對，雙手交叉指縫相互揉搓/r/n4.右手握住左手大拇指旋轉(zhuǎn)揉搓，交換進行/r/n5.彎曲手指使關(guān)節(jié)在另一個手掌心旋轉(zhuǎn)揉搓，交換進行/r/n6.將五個手指尖并攏放在另一個手掌心旋轉(zhuǎn)揉搓，交換進行/r/n7.流動水下徹底沖洗/r/n8.擦干雙手〔用一次性紙巾/毛巾徹底擦干用干枯燥雙手〕/r/n9/r/n．關(guān)閉水龍頭采用防止手部再污染的方法/r/n10/r/n10/r/n10/r/n10/r/n10/r/n10/r/n3/r/n2/r/n5/r/n8/r/n8/r/n8/r/n8/r/n8/r/n8/r/n2/r/n1/r/n4/r/n6/r/n6/r/n6/r/n6/r/n6/r/n6/r/n1/r/n0/r/n3/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n0/r/n0/r/n2/r/n評價/r/n5分/r/n無污染、完成時間2/r/n分鐘/r/n5/r/n4/r/n3/r/n2/r/n提問/r/n5分/r/n5/r/n4/r/n3/r/n2/r/n總分/r/n110/r/n提問：1、說明/r/n一般/r/n洗手具體指征。/r/n〔2.5分〕/r/n答復一般洗手的考前須知?！?.5分〕/r/n二、無菌技術(shù)/r/n無菌持物鉗的使用法/r/n〔一〕目的/r/n：/r/n取用或者傳遞無菌的敷料、器械等。/r/n〔二〕實施要點/r/n1.評估操作環(huán)境是否符合要求。/r/n2.檢查無菌持物鉗包有無破損、潮濕、消毒指示膠帶是否變色及其有效期。/r/n3.翻開無菌鉗包，取出鑷子罐置于治療臺面上。/r/n4.取放無菌鉗時，鉗端閉合向下，不可觸及容器口邊緣，用后立即放回容器內(nèi)。/r/n5.標明翻開日期及時間。/r/n〔三〕考前須知/r/n1.無菌持物鉗不能夾取未滅菌的物品，也不能夾取油紗布。/r/n2.取遠處物品時，應當連同容器一起搬移到物品旁使用。/r/n3.使用無菌鉗時不能低于腰部。/r/n4.翻開包后的干鑷子罐、持物鉗應當4小時更換。/r/n戴無菌手套法/r/n〔一〕目的/r/n：/r/n執(zhí)行無菌操作或者接觸無菌物品時戴無菌手套，以保護患者，預防感染。/r/n〔二〕/r/n實施要點/r/n1.評估操作環(huán)境是否符合要求。/r/n2.選擇尺碼適宜的無菌手套,檢查有無破損、潮濕及其有效期。/r/n3.取下手表，洗手。/r/n/r/n4.按照無菌技術(shù)原那么和方法戴無菌手套。/r/n5.雙手對合交叉調(diào)整手套位置，將手套翻邊扣套在工作服衣袖外面。/r/n〔三〕考前須知/r/n1.戴手套時應當注意未戴手套的手不可觸及手套的外面，戴手套的手不可觸及未戴手套的手或者另一手套的里面。/r/n2.戴手套后如發(fā)現(xiàn)有破洞，應當立即更換。/r/n3.脫手套時，應翻轉(zhuǎn)脫下。/r/n取用無菌溶液法/r/n〔一〕目的/r/n:/r/n保持無菌溶液的無菌狀態(tài)。/r/n〔二〕實施要點/r/n1.評估操作環(huán)境是否符合要求。/r/n2.對所使用的無菌溶液進行檢查、核對。/r/n3.按照無菌技術(shù)要求取出無菌液體。/r/n4.手握標簽面，先倒少量溶液于彎盤內(nèi)，再由原處倒所需液量于無菌容器內(nèi)，蓋好治療巾。/r/n5.取用后立即塞上橡膠塞，消毒瓶塞邊緣。/r/n6.記錄開瓶日期、時間，已翻開的溶液有效使用時間是24小時。/r/n〔三〕考前須知/r/n1.不可以將無菌物品或者非無菌物品伸入無菌溶液內(nèi)蘸取或者直接接觸瓶口倒液。/r/n2.已倒出的溶液不可再倒回瓶內(nèi)。/r/n無菌容器使用法/r/n〔一〕目的/r/n:/r/n保持已經(jīng)滅菌的物品處于無菌狀態(tài)。/r/n〔二〕實施要點/r/n1.評估操作環(huán)境是否符合要求。/r/n2.翻開無菌容器時，應當將容器蓋內(nèi)面朝上置于穩(wěn)妥處，或者拿在手中。/r/n3.用畢即將容器蓋嚴。/r/n/r/n/r/n4.手持無菌容器時,應當托住底部。/r/n5.從中取物品時，應將蓋子全部翻開，防止物品觸碰邊緣而污染。/r/n〔三〕考前須知/r/n1.使用無菌容器時，不可污染蓋內(nèi)面、容器邊緣及內(nèi)面。/r/n2.無菌容器翻開后，記錄開啟的日期、時間，有效使用時間為24小時。/r/n鋪無菌盤法/r/n〔一〕/r/n目的/r/n:/r/n將無菌巾鋪在清潔枯燥的治療盤內(nèi)，形成無菌區(qū)，放置無菌物品，以供實施治療時使用。/r/n〔二〕實施要點/r/n1.評估操作環(huán)境是否符合要求。/r/n2.檢查無菌包有無破損、潮濕、消毒指示膠帶是否變色及其有效期。/r/n3.翻開無菌包，用無菌鉗取出1塊治療巾，放于治療盤內(nèi)。/r/n4.雙手捏住無菌巾上層兩角的外面，輕輕抖開，雙折鋪于治療盤內(nèi)，上層向遠端呈扇形折疊，開口邊向外。/r/n5.放入無菌物品后，將上層蓋于物品上，上下層邊緣對齊，開口處向上翻折兩次，兩側(cè)邊緣向下翻折一次。/r/n〔三〕考前須知/r/n1.鋪無菌盤區(qū)域必須清潔枯燥，無菌巾防止潮濕。/r/n/r/n/r/n2.非無菌物品不可觸及無菌面。/r/n3.注明鋪無菌盤的日期、時間，無菌盤有效期為4小時。/r/n無菌技術(shù)操作考核評分標準/r/n單位及科室：/r/n被考核人：/r/n主考核人：/r/n考核日期：/r/n/r/n項/r/n/r/n目/r/n總分/r/n評分細那么/r/n評分等級/r/nA/r/nB/r/nC/r/nD/r/n儀/r/n/r/n表/r/n5/r/n儀表端莊，服裝整潔/r/n5/r/n4/r/n3/r/n2/r/n評/r/n/r/n估/r/n4/r/n4/r/n3/r/n2/r/n1/r/n操作前準備/r/n5/r/n環(huán)境清潔/r/n洗手，戴口罩/r/n2/r/n2/r/n1/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n操/r/n作/r/n過/r/n程/r/n無菌鉗使用/r/n18/r/n1/r/n．拿持物鉗〔鑷〕方法正確，用物符合無菌標準/r/n2/r/n．注明、注意啟用時間/r/n6/r/n6/r/n6/r/n4/r/n4/r/n4/r/n2/r/n2/r/n2/r/n0/r/n0/r/n0/r/n無/r/n菌/r/n包/r/n使/r/n用/r/n12/r/n1./r/n包皮、無菌物品消毒時間符合要求/r/n5./r/n注明開包時間〔夏、冬季標準〕/r/n2/r/n2/r/n3/r/n3/r/n2/r/n1/r/n1/r/n2/r/n2/r/n1/r/n0/r/n0/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n無/r/n菌/r/n容/r/n器/r/n使/r/n用/r/n12/r/n1./r/n容器開蓋方法正確、無污染/r/n2/r/n3/r/n3/r/n2/r/n2/r/n1/r/n2/r/n2/r/n1/r/n1/r/n0/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n無/r/n菌/r/n溶/r/n液/r/n使/r/n用/r/n10/r/n2./r/n開瓶蓋方法正確，不污染/r/n3./r/n倒液方法正確，不污染/r/n4./r/n蓋瓶口方法正確，不污染，標注開瓶時間/r/n3/r/n2/r/n3/r/n2/r/n2/r/n1/r/n2/r/n1/r/n1/r/n0/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n鋪/r/n無/r/n菌/r/n盤/r/n12/r/n2/r/n3/r/n2/r/n3/r/n2/r/n1/r/n2/r/n1/r/n2/r/n1/r/n0/r/n1/r/n0/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n無/r/n菌使/r/n手用/r/n套法/r/n12/r/n3/r/n3/r/n6/r/n2/r/n2/r/n5/r/n1/r/n1/r/n4/r/n0/r/n0/r/n3/r/n/r/n評/r/n/r/n價/r/n5/r/n動作準確、熟練、節(jié)力/r/n操作過程無污染/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n/r/n提/r/n/r/n問/r/n5/r/n5/r/n4/r/n3/r/n2/r/n/r/n總/r/n/r/n分/r/n100/r/n提問：/r/n1、/r/n使用無菌持物鉗的考前須知是哪些內(nèi)容?/r/n〔2.5分〕/r/n2/r/n、/r/n戴無菌手套的目的是什么?/r/n〔2.5分〕/r/n三、生命體征監(jiān)測技術(shù)/r/n體溫的測量/r/n〔一〕目的/r/n:/r/n/r/n1.測量、記錄患者體溫。/r/n/r/n/r/n2.監(jiān)測體溫變化，分析熱型及伴隨病癥。/r/n〔二〕實施要點/r/n1.評估患者：/r/n(1)詢問、了解患者的身體狀況，向患者解釋測量體溫的目的，取得患者的配合。/r/n(2)評估患者適宜的測溫方法。/r/n2.操作要點：/r/n(1)洗手，檢查體溫計是否完好，將水銀柱甩至35度以下。/r/n(2)根據(jù)患者病情、年齡等因素選擇測量方法。/r/n(3)測腋溫時應當擦干腋下的汗液，將體溫計/r/n水銀端/r/n放于患者腋/r/n窩深處并/r/n緊/r/n皮膚，防止脫落。測量5/r/n—/r/n10分鐘后取出。/r/n(4)測口溫時應當將水銀端斜放于患者舌下，閉口3分鐘后取出。/r/n(5)測肛溫時應領(lǐng)先在肛表前端涂潤滑劑，將肛溫計的水銀端輕輕插入肛門3/r/n-4厘米/r/n，3分鐘后取出。用消毒紗布擦拭體溫計。/r/n(6)/r/n讀取體溫數(shù)，消毒體溫計。/r/n3.指導患者：/r/n(1)/r/n告知患者/r/n測口溫前15-30分鐘勿進食過冷、過熱食物，測口溫時閉口用鼻呼吸，勿用牙咬體溫計。/r/n(2)/r/n根據(jù)患者實際情況，可以指導患者學會正確測量體溫的方法。/r/n〔三〕考前須知/r/n1.嬰幼兒、意識不清或者不合作的患者測體溫時，護理人員應當守候在患者身旁。/r/n2.如有影響測量體溫的因素時，應當推遲30分鐘測量。/r/n3./r/n發(fā)現(xiàn)體溫和病情不符時，應當復測體溫。/r/n4.極度消瘦的患者不宜測腋溫。/r/n5/r/n./r/n如患者不慎咬破汞溫度計，應當立即去除口腔內(nèi)玻璃碎片，再口服蛋清或者牛奶延緩汞的吸收。假設(shè)病情允許，服富含纖維食物以促進汞的排泄。/r/n脈搏的測量/r/n〔一〕目的/r/n:/r/n1.測量患者的脈搏，判斷有無異常情況。/r/n2.監(jiān)測脈搏變化，間接了解心臟的情況。/r/n〔二〕實施要點/r/n1.評估患者：/r/n(1)詢問、了解患者的身體狀況。/r/n/r/n(2)向患者講解測量脈搏的目的，取得患者的配合。/r/n2.操作要點:/r/n(1)協(xié)助患者采取舒適的姿勢，手臂輕松置于床上或者桌面。/r/n(2)以食指、中指、無名指的指端按壓橈動脈，力度適中，以能感覺到脈搏搏動為宜。/r/n(3)一般患者可以測量30秒，脈搏異常的患者，測量1分鐘，核實后，報告醫(yī)師。/r/n3.指導要點：/r/n(1)告/r/n知患者測量脈搏時的考前須知。/r/n(2)/r/n根據(jù)患者實際情況，可以指導患者學會正確測量脈搏的方法。/r/n〔三〕考前須知/r/n1.如患者有緊張、劇烈運動、哭鬧等情況，需穩(wěn)定后測量。/r/n2.脈搏短絀的患者，按要求測量脈搏，即一名護士測脈搏，另一名護士聽心率，同時測量1分鐘。/r/n呼吸的測量/r/n(一)目的/r/n：/r/n1.測量患者的呼吸頻率。/r/n/r/n/r/n2.監(jiān)測呼吸變化。/r/n〔二〕實施要點/r/n１/r/n、/r/n評估患者：/r/n/r/n詢問、了解患者的身體狀況及一般情況。/r/n2/r/n、/r/n操作要點：/r/n(1)觀察患者的胸腹部，一起一伏為一次呼吸，測量30秒。/r/n(2)/r/n危重患者呼吸不易觀察時，用少許棉絮置于患者鼻孔前，觀察棉花吹動情況，計數(shù)1分鐘。/r/n〔三〕考前須知/r/n1.呼吸的速率會受到意識的影響，測量時不必告訴患者。/r/n2.如患者有緊張、劇烈運動、哭鬧等，需穩(wěn)定后測量。/r/n3.呼吸不規(guī)律的患者/r/n及嬰兒/r/n應當測量1分鐘。/r/n血壓的測量/r/n〔一〕目的/r/n：/r/n1.測量、記錄患者的血壓，判斷有無異常情況。/r/n2.監(jiān)測血壓變化，間接了解循環(huán)系統(tǒng)的功能狀況。/r/n〔二〕實施要點/r/n1.評估患者：/r/n(1)詢問、了解患者的身體情況；/r/n(2)/r/n告訴患者測量血壓的目的，取得患者的配合。/r/n2.操作要點：/r/n(1)/r/n檢查血壓計。/r/n(2)/r/n協(xié)助患者采取坐位或者臥位，保持血壓計零點、肱動脈與心臟同一水平。/r/n(3)/r/n驅(qū)盡袖帶內(nèi)空氣，平整地纏于患者上臂中部，松緊以能放入一指為宜，下緣距肘窩2-3厘米。/r/n(4)聽診器置于/r/n肱/r/n動脈位置。/r/n(5)按照要求測量血壓，正確判斷收縮壓與舒張壓。/r/n(6)/r/n測量完畢，排盡袖帶余氣，關(guān)閉血壓計。/r/n/r/n(7)/r/n記錄血壓數(shù)值。/r/n3.指導患者：/r/n(1)告知患者測血壓時的考前須知。/r/n(2)/r/n根據(jù)患者實際情況，可以指導患者或者家屬學會正確測量血壓的方法。/r/n〔三〕考前須知/r/n1.保持測量者視線與血壓計刻度平行。/r/n/r/n2/r/n、/r/n長期觀察血壓的患者，做到/r/n“/r/n四定〞/r/n：定時間、定部位、定體位、定血壓計。/r/n3/r/n、/r/n按照要求選擇適宜袖帶。/r/n4/r/n、/r/n假設(shè)/r/n衣袖過緊或者太多時，應當脫掉衣服，以免影響測量結(jié)果。/r/n生命體征監(jiān)測技術(shù)操作考核評分標準/r/n單位及科室：/r/n/r/n被考核人：主考教師：/r/n/r/n考核日期：/r/n項目/r/n總分/r/n評分細那么/r/n評分等級/r/n儀/r/n/r/n表/r/n5/r/n儀表端莊，服裝整潔/r/n5/r/n4/r/n3/r/n2/r/n溝通技巧/r/n10/r/n表情自然，語言親切、流暢、通俗易懂,能完整表達護理要求/r/n10/r/n8/r/n6/r/n4/r/n20/r/n評估患者生命體征情況，〔每項5分，共4項〕/r/n指導患者，并得到配合/r/n20/r/n10/r/n5/r/n2/r/n操作前準備/r/n5/r/n洗手，戴口罩/r/n2/r/n1/r/n0/r/n0/r/n備齊用物，放置合理/r/n3/r/n2/r/n1/r/n0/r/n體溫的測量/r/n15/r/n測量前后核對方法正確，核對內(nèi)容完整/r/n4/r/n1/r/n2/r/n1/r/n患者體位擺放正確/r/n3/r/n2/r/n1/r/n0/r/n操作程序正確/r/n4/r/n3/r/n2/r/n1/r/n測量結(jié)果正確/r/n4/r/n3/r/n2/r/n1/r/n脈搏的測量/r/n15/r/n核對正確/r/n2/r/n1/r/n0/r/n0/r/n患者體位擺放正確/r/n3/r/n2/r/n1/r/n0/r/n操作程序正確/r/n5/r/n4/r/n3/r/n2/r/n測量結(jié)果正確/r/n5/r/n4/r/n3/r/n2/r/n呼吸的測量/r/n15/r/n正確評估病人，分散病人注意力/r/n2/r/n1/r/n0/r/n0/r/n患者體位擺放正確/r/n3/r/n2/r/n1/r/n0/r/n操作程序正確/r/n5/r/n4/r/n3/r/n2/r/n測量結(jié)果正確/r/n5/r/n4/r/n3/r/n2/r/n血壓的測量/r/n15/r/n測量前后核對方法正確，核對內(nèi)容完整/r/n4/r/n3/r/n2/r/n1/r/n患者體位擺放正確/r/n3/r/n2/r/n1/r/n0/r/n操作程序正確/r/n4/r/n3/r/n2/r/n1/r/n測量結(jié)果正確/r/n4/r/n3/r/n2/r/n1/r/n操作后/r/n5/r/n正確處理用物和病人床單/r/n3/r/n2/r/n1/r/n0/r/n操作后記錄簽字、有異常情況及/r/n時通知/r/n醫(yī)師/r/n2/r/n1/r/n0/r/n0/r/n提/r/n/r/n問/r/n5/r/n5/r/n4/r/n3/r/n2/r/n合計/r/n110/r/n提問：/r/n1、/r/n測體溫考前須知?！?.5分〕/r/n2、測血壓的考前須知?！?.5分〕/r/n四、口腔護理技術(shù)/r/n(一)目的/r/n:/r/n1.保持口腔清潔，預防感染等并發(fā)癥。/r/n2.觀察口腔內(nèi)的變化，提供病情變化的信息。/r/n/r/n/r/n3.保證患者舒適。/r/n〔二〕實施要點/r/n１.評估患者：/r/n(1)/r/n詢問、了解患者身體狀況。/r/n(2)/r/n向患者解釋口腔護理的目的，取得患者的配合。/r/n2.操作要點：/r/n(1)/r/n準備用物，/r/n根據(jù)患者病情選擇口腔護理溶液。/r/n(2)/r/n進行口腔護理操作時，防止清潔、污染交叉混淆。/r/n(3)/r/n詢問患者感受，并協(xié)助患者取舒適臥位。/r/n3.指導要點：/r/n(1)/r/n告知患者在操作過程中的配合事項。/r/n(2)/r/n指導患者正確的漱口方法，防止嗆咳或者誤吸。/r/n〔三〕考前須知/r/n1/r/n、/r/n操作動作應當輕柔，防止金屬鉗端碰到牙齒，損傷粘膜及牙齦，/r/n對凝血功能差的患者應當特別注意。/r/n2/r/n、/r/n對昏迷患者應當注意棉球干濕度，禁止漱口。/r/n3/r/n、/r/n使用開口器時，應從臼齒處放入。/r/n4/r/n、/r/n擦洗時須用止血鉗夾緊棉球，每次一個，防止棉球遺留在口腔內(nèi)。/r/n/r/n5/r/n、/r/n如患者有活動的假牙，應先取下再進行操作。/r/n6/r/n、/r/n護士操作前后應當清點棉球數(shù)量。/r/n口腔護理技術(shù)操作考核評分標準/r/n單位及科室：被考核人：主考教師：考核日期：/r/n項目/r/n總分/r/n評分細那么/r/n評分等級/r/n儀/r/n/r/n表/r/n5/r/n儀表端莊，服裝整潔/r/n5/r/n4/r/n3/r/n2/r/n溝通技巧/r/n10/r/n表情自然，語言親切、流暢、通俗易懂,能完整表達護理要求/r/n10/r/n8/r/n6/r/n4/r/n評估與指導/r/n10/r/n1．/r/n詢問、了解患者身體狀況，口腔狀況/r/n2．/r/n解釋、指導，取得患者的配合/r/n5/r/n5/r/n4/r/n4/r/n3/r/n3/r/n2/r/n2/r/n操作前準備/r/n10/r/n1./r/n洗手、戴口罩/r/n2./r/n根據(jù)病情需要準備藥液及用物/r/n3./r/n備齊用物，放置合理/r/n2/r/n6/r/n2/r/n1/r/n5/r/n1/r/n0/r/n4/r/n0/r/n0/r/n3/r/n0/r/n操/r/n作/r/n過/r/n程/r/n平安與舒適/r/n10/r/n1.病人接受操作的環(huán)境舒適/r/n2.病人體位舒適〔側(cè)臥或頭偏向一側(cè)〕/r/n3.假牙處理/r/n4.使用棉球數(shù)量清點/r/n2/r/n3/r/n3/r/n2/r/n1/r/n2/r/n2/r/n1.5/r/n0/r/n1/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n操/r/n作/r/n中/r/n50/r/n1.擦口唇、漱口/r/n2./r/n頜下鋪巾、放置彎盤位置適當/r/n3./r/n正確使用壓舌板、開口器等/r/n4./r/n夾取棉球或紗布方法正確/r/n5./r/n棉球濕度適宜/r/n6./r/n擦洗順序、方法正確/r/n7./r/n口腔疾患處理正確/r/n8./r/n擦洗過程隨時詢問病人的感受/r/n9./r/n幫助病人擦凈面部/r/n10.操作中不污染床單及病/r/n人衣服/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n操作后/r/n5/r/n使用后物品整理/r/n指導患者正確的漱口方法及意義/r/n2/r/n3/r/n1/r/n2/r/n0/r/n1/r/n0/r/n0/r/n評/r/n/r/n價/r/n5/r/n嚴格執(zhí)行查對制度/r/n操作中了解患者感受、溝通能力/r/n區(qū)分清潔、干凈，無交叉污染/r/n2/r/n2/r/n1/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n提/r/n/r/n問/r/n5/r/n5/r/n4/r/n3/r/n2/r/n總分/r/n110/r/n提問：/r/n/r/n口腔護理的考前須知？/r/n五、鼻飼技術(shù)/r/n〔一〕目的 /r/n對不能經(jīng)口進食的患者，從胃管灌入流質(zhì)食物，保證患者攝入足夠的營養(yǎng)、水分和藥物，以利早日康復。/r/n〔二〕實施要點/r/n1.評估患者：/r/n(1)/r/n/r/n詢問患者身體狀況，了解患者既往有無插管經(jīng)歷。/r/n(2)/r/n/r/n向患者解釋，取得患者合作。/r/n(3)/r/n/r/n評估患者鼻腔狀況，包括鼻腔粘膜有無腫脹、炎癥、鼻中隔彎曲、息肉等，既往有無鼻部疾患。/r/n2.操作要點：/r/n(1)核對醫(yī)囑，準備用物。/r/n/r/n/r/n/r/n(2)根據(jù)醫(yī)囑準備鼻飼液。/r/n(3)攜/r/n物品至患者旁/r/n，為患者取適當體位。/r/n(4)/r/n檢查胃管是否通暢，測量胃管放置長度。/r/n(5)/r/n為患者進行插管操作，插入適當深度并檢查胃管是否在胃內(nèi)。/r/n〔/r/n6)選擇適宜位置固定胃管。/r/n(7)灌注鼻飼液。/r/n3.指導要點：/r/n(1)告知患者插胃管和鼻飼可能造成的不良反響。/r/n(2)告知/r/n患者鼻飼操作過程中的不適及配合方法。/r/n(3)/r/n指導患者在惡心時做深呼吸或者吞咽動作。/r/n(4)/r/n指導患者在帶管過程中的考前須知，防止胃管脫出。/r/n〔三〕考前須知/r/n1.插管過程中患者出現(xiàn)嗆咳、呼吸困難、紫紺等，表示誤入氣管，應立即拔出，休息片刻重插。/r/n2.昏迷患者插管時，應將患者頭向后仰，當胃管插入會厭部時約15厘米,左手托起頭部，使下頜靠近胸骨柄，加大咽部通道的弧度，使管端沿后壁滑行，插至所需長度。/r/n3.每天檢查胃管插入的深度，鼻飼前檢查胃管是否在胃內(nèi)，并檢查患者有無胃潴留，胃內(nèi)容物超過150毫升時，應當通知醫(yī)師減量或者暫停鼻飼。/r/n4.鼻飼給藥時應先研碎，溶解后注入，鼻飼前后均應用20毫升水沖洗導管，防止管道堵塞。/r/n5.鼻飼混合流食，應當間接加溫，以免蛋白凝固。/r/n/r/n/r/n6.對長期鼻飼的患者，應當定期更換胃管。/r/n第五項鼻飼技術(shù)操作考核評分標準/r/n單位及科室：被考核人：主考教師：/r/n/r/n考核日期：/r/n項目/r/n總分/r/n評分細那么/r/n評分等級/r/nA/r/nB/r/nC/r/nD/r/n儀表/r/n5/r/n儀表端莊，服裝整潔/r/n5/r/n4/r/n3/r/n2/r/n溝通技巧/r/n10/r/n表情自然，語言親切、流暢、通俗易懂,能完整表達護理要求/r/n10/r/n8/r/n6/r/n4/r/n評估與指導/r/n10/r/n傾聽病人的需要和反響/r/n2．/r/n解釋、指導，取得患者的配合/r/n5/r/n5/r/n4/r/n4/r/n3/r/n3/r/n2/r/n2/r/n操作前準備/r/n5/r/n備齊用物，放置合理/r/n洗手，戴口罩/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n操/r/n作/r/n過/r/n程/r/n平安與/r/n舒適/r/n10/r/n環(huán)境安靜、清潔/r/n病人體位舒適，讓病人放松、配合/r/n核查有無不平安隱患?！膊閷?、插管、喂食全過程〕/r/n2/r/n3/r/n5/r/n1/r/n2/r/n4/r/n0/r/n1/r/n3/r/n0/r/n0/r/n2/r/n插/r/n胃/r/n管/r/n30/r/n頜下鋪巾/r/n清潔并檢查鼻腔/r/n滑潤導管并檢查是否通暢/r/n判斷胃管的位置方法正確/r/n胃管固定牢固、美觀/r/n2/r/n2/r/n2/r/n10/r/n7/r/n5/r/n2/r/n1/r/n1/r/n1/r/n8/r/n5/r/n4/r/n1/r/n0/r/n0/r/n0/r/n6/r/n3/r/n3/r/n0/r/n0/r/n0/r/n0/r/n4/r/n2/r/n2/r/n0/r/n鼻/r/n飼/r/n26/r/n1．喂食步驟正確、速度適宜；〔先抽試，再沖水、灌食〕/r/n2/r/n．食量、溫度適宜/r/n4/r/n．完畢用適量溫水沖洗、清潔管腔/r/n5/r/n．正確處理管端〔管子末端反折，紗布包好夾緊〕/r/n10/r/n5/r/n3/r/n4/r/n4/r/n8/r/n5/r/n2/r/n3/r/n3/r/n6/r/n3/r/n1/r/n2/r/n2/r/n4/r/n2/r/n0/r/n1/r/n1/r/n操作后/r/n4/r/n妥善安置病人、整理床單位/r/n用物處理正確并記錄/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n評價/r/n5/r/n病人舒適，無不良反響/r/n步驟正確，潔、污分開/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n提問/r/n5/r/n5/r/n4/r/n3/r/n2/r/n總分/r/n110/r/n提問：/r/n1、/r/n鼻飼的考前須知有哪些？〔2.5分〕/r/n/r/n2/r/n、/r/n答復確定胃管在胃內(nèi)的方法?！?.5分〕/r/n六、導尿技術(shù)及護理/r/n〔一〕目的/r/n：/r/n1.采集患者尿標本做細菌培養(yǎng)。/r/n2.為尿潴留患者引流尿液，減輕痛苦。/r/n3.用于患者術(shù)前膀胱減壓以及下腹、盆腔器官手術(shù)中持續(xù)排空膀胱，防止術(shù)中誤傷。/r/n4.患者尿道損傷早期或者手術(shù)后作為支架引流，經(jīng)導尿管對膀胱進行藥物灌注治療。/r/n5.患者昏迷、尿失禁或者/r/n會陰部有損傷時，留置導尿管以保持局部枯燥、清潔，防止尿液的刺激。/r/n6.搶救休克或者危重患者，準確記錄尿量、比重，為病情變化提供依據(jù)。/r/n7.為患者測定膀胱容量、壓力及剩余尿量,向膀胱注入造影劑或者氣體等以協(xié)助診斷。/r/n〔二〕實施要點/r/n1.評估患者:/r/n(1)詢問、了解患者的身體狀況/r/n。/r/n(2)/r/n向患者解釋導尿的目的、考前須知，取得患者的配合。/r/n(3)了解患者/r/n膀胱充盈度及局部皮膚情況/r/n2.操作要點:/r/n(1)/r/n(2)/r/n攜用物至患者旁，/r/n關(guān)閉門窗，為患者遮擋，協(xié)助患者做好準備。/r/n(3)按照無菌操作原那么實施導尿操作。/r/n(4)插入導尿管后注入10-15毫升無菌生理鹽水，輕拉尿管以證實尿管固定穩(wěn)妥。/r/n3.指導患者：/r/n(1)指導患者放松，在插管過程中協(xié)調(diào)配合，防止污染。/r/n(2)指導患者在留置尿管期間保證充足入量，預防發(fā)生感染和結(jié)石。/r/n(3)告知患者在留置尿管期間防止尿管打折、彎曲、受壓、脫出等情況發(fā)生，保持通暢。/r/n(4)告知患者保持尿袋高度低于恥骨聯(lián)合水平，防止逆行感染。/r/n/r/n(5)指導長期留置尿管的患者進行膀胱功能訓練及骨盆底肌的鍛煉，以增強控制排尿的能力。/r/n〔三〕考前須知/r/n/r/n/r/n1/r/n、/r/n患者留置尿管期間，尿管要定時夾閉。/r/n2/r/n、/r/n尿潴留患者一次導出尿量不超過1000毫升，以防出現(xiàn)虛脫和血尿。/r/n3/r/n、/r/n患者尿管拔除后，觀察患者排尿時的異常病癥。/r/n4/r/n、/r/n為男性患者插尿管時,遇有阻力，特別是尿管經(jīng)尿道內(nèi)口、膜部、尿道外口的狹窄部、恥骨聯(lián)合下方和前下方處的彎曲部時，囑患者緩慢深呼吸，慢慢插入尿管。/r/n第六項女病人導尿技術(shù)操作考核評分標準/r/n單位及科室：被考核人：主考教師：/r/n/r/n考核日期：/r/n項目/r/n總分/r/n評分細那么/r/n評分等級/r/nA/r/nB/r/nC/r/nD/r/n儀表/r/n5/r/n儀表端莊，服裝整潔/r/n5/r/n4/r/n3/r/n2/r/n溝通技巧/r/n10/r/n表情自然，語言親切、流暢、通俗易懂,能完整表達護理要求/r/n10/r/n8/r/n6/r/n4/r/n評估與指導/r/n10/r/n1./r/n了解病情、膀胱充盈度、會陰部皮膚、粘膜情況/r/n2./r/n了解病人自理、合作程度、耐受力及心理反響/r/n3./r/n告知導尿目的、方法，語言標準/r/n4./r/n結(jié)合病人實際需要給予指導/r/n2/r/n2/r/n3/r/n3/r/n1/r/n1/r/n2/r/n2/r/n0/r/n0/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n操作前準備/r/n4/r/n1./r/n洗手，戴口罩/r/n2./r/n備齊用物，放置合理/r/n3./r/n指導放松，在插管過程中協(xié)調(diào)配合/r/n1/r/n1/r/n2/r/n1/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n操/r/n作/r/n過/r/n程/r/n平安與/r/n舒適/r/n10/r/n1.環(huán)境安靜、清潔；〔關(guān)門窗、圍屏風〕/r/n2/r/n4/r/n4/r/n1/r/n3/r/n3/r/n0/r/n2/r/n2/r/n0/r/n1/r/n1/r/n導/r/n尿/r/n56/r/n1./r/n術(shù)者體位正確，符合力學原理/r/n2.核對后臀下鋪巾是否固定；〔墊〕/r/n3./r/n協(xié)助病人清潔會陰方法正確并初步消毒，再次清潔雙手/r/n4.翻開導尿包不污染，放置合理/r/n5.使用無菌鉗，物品不污染/r/n6.戴無菌手套方法正確，不污染/r/n7.鋪孔巾方法正確，不污染/r/n8.滑潤導尿管不污染/r/n9./r/n消毒陰唇、尿道口方法正確〔一手分開固定一手消毒〕/r/n10.更換血管鉗后插管方法正確/r/n11.觀察插管深度、尿液及引流情況/r/n12./r/n拔管方法正確并擦凈外陰/r/n2/r/n1/r/n5/r/n3/r/n4/r/n4/r/n6/r/n6/r/n10/r/n8/r/n5/r/n2/r/n1/r/n0/r/n4/r/n2/r/n3/r/n3/r/n5/r/n5/r/n8/r/n6/r/n4/r/n1/r/n0/r/n0/r/n3/r/n/r/n1/r/n2/r/n2/r/n4/r/n4/r/n6/r/n4/r/n3/r/n0/r/n0/r/n0/r/n2/r/n0/r/n1/r/n1/r/n3/r/n3/r/n4/r/n2/r/n2/r/n0/r/n操作后/r/n5/r/n1.協(xié)助病人整理衣褲/床單位，恢復舒適臥位/r/n2.用物處理恰當，洗手后記錄并執(zhí)行簽字/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n評價/r/n5/r/n1、關(guān)愛病人、保護隱私/r/n2、/r/n嚴格遵守無菌技術(shù)/r/n操作及查對制度/r/n2/r/n3/r/n1/r/n2/r/n0/r/n0/r/n0/r/n0/r/n提問/r/n5/r/n5/r/n4/r/n3/r/n2/r/n總分/r/n110/r/n提問：1．答復/r/n導尿的目的?！?.5分〕/r/n/r/n/r/n2./r/n導尿時如何評估患者？/r/n〔2.5分〕/r/n七/r/n、氧氣吸入技術(shù)/r/n〔一〕目的/r/n：/r/n提高患者血氧含量及動脈血氧飽和度，糾正缺氧。/r/n〔二〕實施要點/r/n1.評估患者：/r/n(1)詢問、了解患者身體狀況，向患者解釋，取得配合。/r/n(2)評估患者鼻腔情況。/r/n2.操作要點:/r/n(1)核對醫(yī)囑，做好準備。/r/n(2)攜用物至患者旁，協(xié)助患者取得舒適體位。/r/n(3)用棉簽清潔患者鼻孔。/r/n(4)將氧氣裝置與供氧裝置接通后，連接鼻導管，根據(jù)醫(yī)囑調(diào)節(jié)氧流量。/r/n(5)檢查導管是否通暢，然后將鼻導管輕輕插入患者鼻孔，并進行固定。/r/n3.指導患者:/r/n(1)根據(jù)患者病情,指導患者進行有效呼吸。/r/n(2)告知患者不要自行摘除鼻導管或者調(diào)節(jié)氧流量。/r/n(3)告知患者如感到鼻咽部枯燥不適或者胸悶憋氣時，應當及時通知醫(yī)護人員。/r/n(4)告知患者有關(guān)用氧平安的知識。/r/n〔三〕考前須知/r/n1/r/n、/r/n患者吸氧過程中，需要調(diào)節(jié)氧流量時，應領(lǐng)先將患者鼻導管取下，調(diào)節(jié)好氧流量后，再與患者連接。停止吸氧時，先取下鼻導管，再關(guān)流量表。/r/n2/r/n、/r/n持續(xù)吸氧的患者，應當保持管道通暢，必要時進行更換。/r/n3/r/n、/r/n觀察、評估患者吸氧效果。/r/n第七項鼻塞〔鼻導管〕吸氧技術(shù)操作考核評分標準/r/n單位及科室：/r/n/r/n被考核人：主考教師：考核日期：/r/n項目/r/n總分/r/n評分細那么/r/n評分等級/r/n儀表/r/n5/r/n儀表端莊，服裝整潔/r/n5/r/n4/r/n3/r/n2/r/n溝通技巧/r/n10/r/n表情自然，語言親切、流暢、通俗易懂,能完整表達護理要求/r/n10/r/n8/r/n6/r/n4/r/n評估與指導/r/n10/r/n了解病情、意識及缺氧程度，鼻腔內(nèi)狀況/r/n觀察病人合作程度及心理反響/r/n解釋吸氧目的、配合方法/r/n結(jié)合病人實際情況給予指導/r/n3/r/n2/r/n2/r/n3/r/n2/r/n1/r/n1/r/n2/r/n1/r/n0/r/n0/r/n1/r/n0/r/n0/r/n0/r/n0/r/n操作前準備/r/n10/r/n〔1/r/n〕按需要備齊物品，順序放置，檢查濕化瓶與導管的連接是否通暢/r/n〔2〕/r/n洗手，戴口罩/r/n5/r/n5/r/n4/r/n4/r/n3/r/n3/r/n2/r/n2/r/n操/r/n作/r/n過/r/n程/r/n平安與/r/n舒適/r/n10/r/n檢查用氧平安〔漏氣、明火、有污染〕/r/n病人體位舒適，環(huán)境清潔，告知四防/r/n6/r/n4/r/n5/r/n3/r/n4/r/n2/r/n3/r/n1/r/n吸/r/n氧/r/n30/r/n檢查、清潔鼻腔，連接鼻塞〔鼻導管〕并試通暢/r/n按需要正確調(diào)節(jié)氧氣流量/r/n插鼻塞〔鼻導管〕方法正確/r/n鼻塞〔鼻導管〕插入深度適宜/r/n導管固定牢固，美觀/r/n記錄用氧時間/r/n操作步驟正確〔包括翻開開關(guān)時操作順序〕/r/n5/r/n4/r/n5/r/n5/r/n4/r/n2/r/n5/r/n4/r/n3/r/n4/r/n4/r/n3/r/n1/r/n4/r/n3/r/n2/r/n3/r/n3/r/n2/r/n0/r/n3/r/n2/r/n1/r/n2/r/n2/r/n1/r/n0/r/n2/r/n停/r/n止/r/n吸/r/n氧/r/n20/r/n取下鼻塞〔鼻導管〕方法正確/r/n關(guān)閉氧氣順序正確/r/n幫助病人清潔面部/r/n記錄停氧時間/r/n操作步驟正確〔先撥管后關(guān)氧氣表〕/r/n4/r/n5/r/n3/r/n2/r/n6/r/n3/r/n4/r/n2/r/n1/r/n5/r/n2/r/n3/r/n1/r/n0/r/n4/r/n1/r/n2/r/n0/r/n0/r/n3/r/n操作后/r/n4/r/n1.妥善安置病人和整理用物，洗手并作好護理記錄；/r/n2./r/n3.告/r/n知患者如感到鼻咽部枯燥不適或者胸悶憋氣時，應當及時通知醫(yī)護人員/r/n4./r/n告知患者有關(guān)用氧平安的知識/r/n1/r/n1/r/n1/r/n1/r/n1/r/n1/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n評價/r/n5/r/n動作熟練、步驟正確/r/n嚴格執(zhí)行查對制度、遵守無菌技術(shù)/r/n2/r/n3/r/n1/r/n2/r/n0/r/n1/r/n0/r/n0/r/n提問/r/n5/r/n5/r/n4/r/n3/r/n2/r/n總分/r/n110/r/n提問：1/r/n、/r/n答復/r/n鼻導管給氧氧濃度的計算方法.〔2.5分〕；/r/n2、/r/n為患者吸氧時的考前須知〔2.5分〕。/r/n八/r/n、換藥技術(shù)/r/n〔一〕目的/r/n：/r/n為患者更換傷口敷料，保持傷口清潔，預防、控制傷口感染，促進傷口愈合。/r/n〔二〕實施要點/r/n1.評估患者:/r/n(1)詢問、了解患者的身體狀況。/r/n(2)觀察、了解傷口局部情況/r/n。/r/n2.操作要點:/r/n/r/n/r/n(1)核對醫(yī)囑。/r/n(2)協(xié)助患者取得舒適的體位。/r/n(3)正確暴露傷口。/r/n(4)區(qū)分傷口類型并采取相應的換藥方法。/r/n(5)正確處理傷口并固定。/r/n3.指導患者:/r/n(1)告知患者換藥的目的及配合事項。/r/n(2)告知患者注意保持傷口敷料清潔枯燥，敷料潮濕時應當及時更換。/r/n〔三〕考前須知/r/n１.嚴格執(zhí)行無菌操作原那么。/r/n2.包扎傷口時要保持良好血液循環(huán)，不可固定太緊，包扎肢體時應從身體遠端到近端，促進靜脈回流/r/n。/r/n第八項換藥技術(shù)操作考核評分標準/r/n單位及科室：被考核人：主考教師：/r/n/r/n考核日期：/r/n項目/r/n總分/r/n評分細那么/r/n評分等級/r/nA/r/nB/r/nC/r/nD/r/n儀/r/n/r/n表/r/n5/r/n服裝整潔、儀表端莊/r/n5/r/n4/r/n3/r/n2/r/n溝通技巧/r/n10/r/n表情自然，語言親切、流暢、通俗易懂,能完整表達護理要求/r/n10/r/n8/r/n6/r/n4/r/n評估與指導/r/n10/r/n1/r/n．了解病人身體狀況及觀察傷口局部情況/r/n2/r/n．確定病人的合作能力/r/n3．/r/n解釋、指導，取得配合/r/n3/r/n3/r/n4/r/n2/r/n2/r/n3/r/n1/r/n1/r/n2/r/n0/r/n0/r/n1/r/n操作前準備/r/n6/r/n1/r/n．準備治療車，洗手，戴口罩/r/n2/r/n．備齊用物，放置合理/r/n3/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n操/r/n作/r/n過/r/n程/r/n平安與/r/n舒適/r/n9/r/n環(huán)境安靜、清潔、舒適/r/n核對醫(yī)囑，再次觀察病人傷口/r/n病人體位正確、舒適，注意保暖/r/n3/r/n3/r/n3/r/n2/r/n2/r/n2/r/n1/r/n1/r/n1/r/n0/r/n0/r/n0/r/n操/r/n作/r/n中/r/n45/r/n治療車推至床旁，做好解釋工作/r/n再次核對，正確暴露傷口/r/n區(qū)分傷口類型，并采取相應的換藥方法/r/n取傷口敷料方法正確/r/n消毒傷口方法正確/r/n使用鑷子方法正確/r/n清洗傷口方法正確/r/n固定紗布方法正確/r/n5/r/n5/r/n6/r/n5/r/n6/r/n6/r/n6/r/n6/r/n5/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n3/r/n3/r/n2/r/n3/r/n2/r/n2/r/n2/r/n2/r/n3/r/n2/r/n2/r/n0/r/n2/r/n0/r/n0/r/n0/r/n0/r/n2/r/n操作后/r/n13/r/n妥善安置病人/r/n告知病人換藥后考前須知/r/n用物處理正確/r/n洗手，記錄觀察情況，執(zhí)行簽字/r/n3/r/n4/r/n3/r/n3/r/n2/r/n3/r/n2/r/n2/r/n1/r/n2/r/n1/r/n1/r/n0/r/n1/r/n0/r/n0/r/n評價/r/n7/r/n操作動作輕柔、準確，傷口清潔，敷料平整/r/n操作符合換藥根本原那么、程序，病人無不適/r/n4/r/n3/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n提問/r/n5/r/n5/r/n4/r/n3/r/n2/r/n總分/r/n110/r/n提問：1．/r/n換藥目的是什么/r/n?〔2分〕/r/n2/r/n．/r/n換藥考前須知是什么/r/n?〔3分〕/r/n九/r/n、霧化吸入療法/r/n〔一〕目的/r/n：/r/n1.協(xié)助患者消炎、鎮(zhèn)咳、祛痰。/r/n/r/n2.幫助患者解除支氣管痙攣，改善通氣功能。/r/n3.預防、治療患者發(fā)生呼吸道感染。/r/n〔二〕實施要點/r/n1.評估患者:/r/n/r/n詢問、了解患者身體狀況，向患者解釋霧化吸入的目的，取得患者合作。/r/n2.操作要點:/r/n(1)核對醫(yī)囑，正確配置藥液,做好準備。/r/n(2)攜物品至患者旁,幫助患者取適宜體位。/r/n(3)翻開霧化開關(guān)，調(diào)節(jié)霧量，將面罩罩住患者口鼻。/r/n(4)掌握正確的霧化方法和時間。/r/n3.指導患者:/r/n(1)指導患者用口吸氣、鼻呼氣的方法。/r/n(2)告知患者如有不適時，及時通知醫(yī)護人員。/r/n〔三〕考前須知/r/n1.水槽和霧化罐中切忌加溫水或者熱水。/r/n/r/n2.水溫超過/r/n60/r/n℃/r/n3.水槽內(nèi)無足夠的冷水及霧化罐內(nèi)無液體的情況下不能開機。/r/n第九項霧化吸入技術(shù)操作考核評分標準/r/n單位及科室：/r/n/r/n被考核人：主考教師：/r/n/r/n考核日期：/r/n項目/r/n總分/r/n評分細那么/r/n評分等級/r/nA/r/nB/r/nC/r/nD/r/n儀/r/n/r/n表/r/n5/r/n儀表端莊，服裝整潔/r/n5/r/n4/r/n3/r/n2/r/n溝通技巧/r/n10/r/n表情自然，語言親切、流暢、通俗易懂,能完整表達護理要求/r/n10/r/n8/r/n6/r/n4/r/n評估與指導/r/n5/r/n1/r/n．評估患者病情及合作程度/r/n2．/r/n解釋、指導，取得患者的配合/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n操作前準備/r/n5/r/n洗手，戴口罩/r/n檢查儀器、備齊用物，放置合理/r/n2/r/n3/r/n1/r/n2/r/n0/r/n1/r/n0/r/n0/r/n操/r/n作/r/n過/r/n程/r/n70/r/n1．核對正確/r/n2．正確配置藥物/r/n3．患者體位擺放正確/r/n4．操作程序正確/r/n5．水槽內(nèi)有足夠的冷水/r/n6．霧化操作方法正確/r/n7．霧化時間正確/r/n8．注意觀察患者病情變化，并及時告知醫(yī)師/r/n9/r/n9/r/n9/r/n9/r/n9/r/n9/r/n7/r/n9/r/n7/r/n7/r/n7/r/n7/r/n7/r/n7/r/n5/r/n7/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n3/r/n5/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n1/r/n3/r/n操作后/r/n5/r/n處理用物方法正確/r/n操作結(jié)束洗手、簽字/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n評/r/n/r/n價/r/n5/r/n操作順序正確、熟練/r/n正確指導患者霧化吸入和排痰/r/n2/r/n3/r/n1/r/n2/r/n0/r/n1/r/n0/r/n0/r/n提/r/n/r/n問/r/n5/r/n5/r/n4/r/n3/r/n2/r/n總分/r/n110/r/n提問：1/r/n、/r/n霧化吸入的目的是什么?〔2.5分〕/r/n2/r/n、/r/n如何指導患者進行正確的霧化吸入?〔2.5分〕/r/n十、口服給藥法/r/n〔一〕目的/r/n：/r/n按照醫(yī)囑正確為患者實施口服給藥，并觀察藥物作用。/r/n〔二〕實施要點/r/n1.評估患者:/r/n(1)詢問、了解患者的身體狀況、藥物過敏史及藥物使用情況。/r/n(2)觀察患者口咽部是否有潰瘍、糜爛等情況。/r/n2.操作要點:/r/n(1)發(fā)藥前進行核對。/r/n(2)按規(guī)定時間送藥至患者旁，核對床號、姓名無誤后再發(fā)藥。/r/n(3)協(xié)助患者服藥，為鼻飼患者給藥時，應當將藥物研碎溶解后由胃管注入。/r/n(4)假設(shè)患者不在病房或者因故暫不能服藥者，暫不發(fā)藥，并做好交班。/r/n(5)/r/n觀察患者服藥效果及不良反響。/r/n3.指導患者：/r/n(1)告知患者所服的藥物、服用方法。/r/n(2)告知患者特殊藥物服用的考前須知。/r/n〔三〕考前須知/r/n１/r/n、/r/n嚴格執(zhí)行查對制度。/r/n２/r/n、/r/n掌握患者所服藥物的作用、不良反響以及某些藥物服用的特殊要求。/r/n３/r/n、/r/n對服用強心甙類藥物的患者,服藥前應領(lǐng)先測脈搏、心率、注意其節(jié)律變化，如脈率低于/r/n60次/分鐘或者節(jié)律不齊時，不可以服用。/r/n第十項口服給藥技術(shù)操作考核評分標準/r/n單位及科室：被考核人：主考教師：考核日期：/r/n項目/r/n總分/r/n評分細那么/r/n評/r/n/r/n分/r/n/r/n等/r/n/r/n級/r/nA/r/nB/r