First, critically ill patients basic care routine
⒈ warm reception of patients, the patient placed in the emergency room or intensive care unit,Patient Care Equipment to keep the indoor air fresh, warm and humidity appropriate; good patient and family members of the hospital (Section) mission.
⒉ timely assessment:
Including the basic situation, the main symptoms, skin conditions, positive auxiliary examination, a variety of pipes, drug treatment and so on.
⒊ emergency care measures: the rapid establishment of venous access (depending on the condition and drug properties to adjust the drip rate), oxygen (depending on the condition to adjust the oxygen flow), ECG monitoring, indwelling catheterization, warm, do a variety of specimen collection,Patient Care Equipment to assist the corresponding Check, if necessary, active preoperative preparation
⒋ supine and safe
⑴ according to the disease to take appropriate position.
⑵ to maintain airway patency, the coma patients should be timely suction nose and nose and endotracheal secretions, to oxygen inhalation.
⑶ teeth closed, convulsions of the patient can be used dental pads, openings, to prevent tongue bites, tongue suffix.
⑷ high fever, coma, delirium, irritability, frail and infants and young children should be added fence, if necessary, to give the band, to prevent the bed, to ensure patient safety.
⑸ prepare all the rescue supplies, drugs and equipment, indoor rescue set up standby state.
⒌ close observation of the condition: personal care,Patient Care Equipment the patient's vital signs, consciousness, pupil, bleeding, SpO2, CVP, peripheral circulation and urine and other conditions of dynamic observation; with the doctor actively rescue, do nursing records.
⒍ prescribed prescribed medication, the implementation of oral doctor's advice, to be repeated without permission to use.
⒎ keep a variety of pipes smooth, properly fixed, safe place to prevent off, twisted, blocked; strict sterile technology to prevent retrograde infection.
⒏ to keep the toilet smooth: urinary retention to take methods to help urinate; if necessary catheterization; constipation as the condition to enema.
⒐ depending on the condition to be diet care: to maintain water, electrolyte balance and to meet the basic needs of the body nutrition; fasting patients may be peripheral venous nutrition.
Basic care
9, the hair, eyes, body, mouth, nose, hand, foot, perineum, anus, skin clean; five to the bed: the first three, Medicine, nursing, rice, medicine, water to the patient bed).
⑵ morning, evening care 2 times a day; urethral mouth care 2 times a day; tracheotomy care 2 times a day; pay attention to eye protection.
⑶ to maintain limb function, to strengthen the passive activities of the body or to help active activities.
⑷ good breathing cough training, every 2h to help patients turn over, shoot back, guide for deep breath, to help discharge secretions.
⑸ strengthen the skin care, prevention of pressure sores.
⒒ psychological care: timely patrol, care for patients,Patient Care Equipment according to the situation to communicate with their families, the establishment of a good nurse-patient relationship, in order to obtain patient trust, family cooperation and understanding.
Second, coma patients care routine
(I) Observe points
⒈ close observation of vital signs (T, P, R, BP), pupil size, light response.
⒉ assess the GLS disturbance of consciousness index and the degree of response to understand the degree of coma, found changes immediately reported to the doctor.
⒊ observation of patients with water, electrolyte balance, record the amount of 24 hours, to provide guidance for the basis of rehydration.
⒋ pay attention to check the patient's stool, observe whether the potential response.
(2) nursing points
⒈ call the patient: operation, the first to call its name, explain the purpose of the operation and precautions.
⒉ to establish and maintain a smooth airway: take the side of the head side to the side, at any time to clear the tracheal secretions, ready to suck things, at any time suction.
⒊ to maintain intravenous infusion: strict record of the amount of drugs used.
⒋ to maintain limb functional bit, regular physical activity and massage to provide physical, prevention of hand, foot and contracture, deformation and nerve palsy.
⒌ to promote brain function recovery: raise the bed 30 to 45 degrees or to give semi-recumbent posture, prescribed medical treatment and oxygen inhalation.
⒍ to maintain the normal excretion function: regular examination of patients with bladder urinary retention, on time to give bed toilet, to help massage the lower abdomen to promote urination, catheterization or replacement of urine bags should pay attention to aseptic technology.
⒎ to maintain clean and comfortable: remove the denture, hairpin, pruning finger (toe) A; daily oral care twice, keep the mouth clean and moist, can be painted paraffin oil (lipstick) to prevent cleft lip; regular sand bath and perineal washing, Replace clean clothes.
⒏ pay attention to safety: agitation should be extra bed, if there is extremely aggravated, appropriate to give constraints; consciousness with high fever convulsions, meningeal irritation,Patient Care Equipment should be given effective cooling and place the tooth pad, to prevent biting cheek; All kinds of piping, to avoid slippage.
⒐ to prevent lung infection: regular turn back to shoot, to stimulate the patient cough, timely suction; keep warm, to avoid cold, the use of hot water when the water temperature is not easy to more than 50 degrees, can not directly contact the skin to prevent burns.
⒑ prevention of pressure sores: the use of air bed, bone protruding part of the sponge pad, keep the bed unit clean and smooth. Every 1 ~ 2h stand up once.
⒒ eye care: remove contact lenses to pay custody. Patients can not close the eyelid, the regular use of saline bristles to wash the eye, with eye ointment or Vaseline oil yarn to protect the cornea,Patient Care Equipment prevention of corneal dryness and inflammation.
(Iii) Health education
⒈ get the family with the guidance of family members to carry out the corresponding awareness of patients to resume training to help patients with passive physical activity and massage.
⒉ psychological care: care to encourage patients,Patient Care Equipment so that patients recognize their own values in the family and society to increase the confidence to overcome the disease.