临床护理技术操作规范

临床护理技术操作规范 一、患者入院护理 (一)工作目标 热情接待患者，帮助其尽快熟悉环境;观察和评估患者病情和护理需求;满足患者安全、舒适的需要。 (二)工作规范要点 1.备好床单位。根据患者病情做好准备工作，并通知医师。2.向患者进行自我介绍，妥善安置患者于病床。3.测量患者生命体征，了解患者的主诉、症状、自理能力、心理状况，填写患者入院相关资料。4.入院告知:向患者/家属介绍主管医师、护士、病区护士长。介绍病区环境、作息时间、探视及有关管理规定等。鼓励患者/家属表达自己的需要及顾虑。5.完成入院护理评估，与医师沟通确定护理级别，遵医嘱实施相关治疗及护理。6.完成患者清洁护理。 (三)结果 1.物品准备符合患者需要，急、危、重患者得到及时救治。2.患者/家属知晓护士的告知事项，对护理服务满意。 二、患者出院护理 (一)工作目标 患者/家属知晓出院指导的内容，掌握必要的康复知识。 (二)工作规范要点 1.告知患者。针对患者病情及恢复情况进行出院指导，包括出院后注意事项、带药指导、饮食及功能锻炼、复诊时间及地点等。2.听取患者住院期间的意见和建议。3.做好出院登记，整理出院病历。4.对患者床单位进行常规清洁消毒。 (三)结果标准 1.患者/家属能够知晓护士的告知事项，对服务满意。2.床单位清洁消毒符合要求。 profile yongxing river level hydropower station pressure pipe pipeline plane Shang along Ridge is line layout, and slope surface contour close vertical, Guan Po with original ground line changes, used open type Ming tube, single tube joint water way, competent diameter 1.3M, long 931.00m, two root non-symmetric "Bu" type support tube, diameter 0.8M, single root long 8.3M. Competent to establish 12 town Pier, 107 buttress, telescopic section 11. Support Pier spacing 8M, side-sliding bearing. Town pier for the closed-end structure of gravity, base surface into bedrock, pipe excavation slope 1:0.75 with M5 grouted rubble slope protection, 0.3M, bottom side sewer, 0.25m wide, deep 0.3m,M5 grouted rubble masonry, set maintenance step ladder on the left side, 1.0M wide. Yongxinghe-? hydropower station penstock pipes arranged along the ridge line on the plane, and nearly vertical slope contour lines, Guan Po changes with the original ground line, with shallow backfill-pipe, single-pipe water supply, the competent 1.4m, long 1063.506m, two asymmetric "y" pipe, diameter 0.8M, single 10m. Competent to establish 12 town Pier, 8 expansion joint. Town pier for the closed-end structure of gravity, placed on soft rock base surface, pipe concrete C20 on a pedestal. Pipe trench excavation slope 1:0.75, after the installation of steel tube, compacted gravel backfill material to the surface, and 1:100 slope drainage to gutters. Gutter width 0.5M depth 0.5m,M5 grouted rubble masonry. 9.2 main engineering content this standard pressure pipe and the metal structure installation part main including Yunnan province tengchong County yongxing River primary and secondary hydropower station in the of pressure pipe and the power station metal structure, which level power station pressure pipe total about 562t (containing annex); II level power station pressure pipe about 733 t (containing annex); level power station metal structure about 52.5 t, containing discharge Gate 2 hole, rushed sand Gate 1 hole, water mouth work door and the stopped dirt gate the 1 hole, Qian pool work door and the stopped dirt gate the 1 hole; Secondary power station metal junction at about 19.5 t, containing sand Gate 1 hole, water inlet water gate and trash the 1 hole; their auxiliary hoist equipment and electrical 三、生命体征监测技术 (一)工作目标 安全、准确、及时测量患者的体温、脉搏、呼吸、血压，为疾病诊疗和制定护理措施提供依据。 (二)工作规范要点 1.告知患者，做好准备。测量体温前30分钟避免进食、冷热饮、冷热敷、洗澡、运动、灌肠、坐浴等影响体温的因素。2.对婴幼儿、老年痴呆、精神异常、意识不清、烦躁和不合作者，护士应在床旁协助患者测量体温。3.测腋温时应当擦干腋下，将体温计放于患者腋窝深处并贴紧皮肤，防止脱落。测量5—10分钟后取出。4.测口温时应当将体温计斜放于患者舌下，用鼻呼吸，闭口3分钟后取出。5.测肛温时应当先在肛表前端涂润滑剂，将肛温计轻轻插入肛门3-4厘米，3分钟后取出。用消毒纱布擦拭体温计。6.发现体温和病情不相符时，应当复测体温。7.用过的体温计应消毒。8.评估测量脉搏部位的皮肤情况，避免在偏瘫侧、形成动静脉瘘侧肢体、术肢等部位测量脉搏。9.测脉搏时协助患者采取舒适的姿势，以食指、中指、无名指的指端按压桡动脉，力度适中，以能感觉到脉搏搏动为宜。10.一般患者可以测量30秒，脉搏异常的患者，测量1分钟。11.发现有脉短绌，应两人同时分别测量，一人测心率，一人测脉搏。12.测量呼吸时患者取自然体位，护士保持诊脉手势，观察患者胸部或腹部起伏，测量30秒。危重患者、呼吸困难、婴幼儿、呼吸不规则者测量1分钟。13.观察患者呼吸频率、节律、幅度和类型等情况。14.危重病人呼吸微弱不易观察时，可用棉花少许置鼻孔前，观察棉花吹动情况，并计数。15.测量血压时，协助患者采取坐位或者卧位，保持血压计零点、肱动脉与心脏同一水平。16.驱尽袖带内空气，平整地缠于患者上臂中部，松紧以能放入一指为宜，下缘距肘窝2-3厘米。17.正确判断收缩压与舒张压。如血压听不清或有异常时，应间隔1-2分钟后重新测18.测量完毕，排尽袖带余气，关闭血压计。19.长期观察血压的患者，做到“四定”:定时间、定profile yongxing river level hydropower station pressure pipe pipeline plane Shang along Ridge is line layout, and slope surface contour close vertical, Guan Po with original ground line changes, used open type Ming tube, single tube joint water way, competent diameter 1.3M, long 931.00m, two root non-symmetric "Bu" type support tube, diameter 0.8M, single root long 8.3M. Competent to establish 12 town Pier, 107 buttress, telescopic section 11. Support Pier spacing 8M, side-sliding bearing. Town pier for the closed-end structure of gravity, base surface into bedrock, pipe excavation slope 1:0.75 with M5 grouted rubble slope protection, 0.3M, bottom side sewer, 0.25m wide, deep 0.3m,M5 grouted rubble masonry, set maintenance step ladder on the left side, 1.0M wide. Yongxinghe-? hydropower station penstock pipes arranged along the ridge line on the plane, and nearly vertical slope contour lines, Guan Po changes with the original ground line, with shallow backfill-pipe, single-pipe water supply, the competent 1.4m, long 1063.506m, two asymmetric "y" pipe, diameter 0.8M, single 10m. Competent to establish 12 town Pier, 8 expansion joint. Town pier for the closed-end structure of gravity, placed on soft rock base surface, pipe concrete C20 on a pedestal. Pipe trench excavation slope 1:0.75, after the installation of steel tube, compacted gravel backfill material to the surface, and 1:100 slope drainage to gutters. Gutter width 0.5M depth 0.5m,M5 grouted rubble masonry. 9.2 main engineering content this standard pressure pipe and the metal structure installation part main including Yunnan province tengchong County yongxing River primary and secondary hydropower station in the of pressure pipe and the power station metal structure, which level power station pressure pipe total about 562t (containing annex); II level power station pressure pipe about 733 t (containing annex); level power station metal structure about 52.5 t, containing discharge Gate 2 hole, rushed sand Gate 1 hole, water mouth work door and the stopped dirt gate the 1 hole, Qian pool work door and the stopped dirt gate the 1 hole; Secondary power station metal junction at about 19.5 t, containing sand Gate 1 hole, water inlet water gate and trash the 1 hole; their auxiliary hoist equipment and electrical 部位、定体位、定血压计。20.结果准确记录在护理记录单或绘制在体温单上。21.将测量结果告诉患者/家属。如果测量结果异常，观察伴随的症状和体征，及时与医师沟通并处理。 (三)结果标准 1.护士测量方法正确，测量结果准确。2.记录准确，对异常情况沟通及时。 四、导尿技术 (一)工作目标 遵医嘱为患者导尿，患者能够知晓导尿的目的，能够配合。 (二)工作规范要点 1.遵循查对制度，符合无菌技术、标准预防原则。2.告知患者/家属留置尿管的目的、注意事项，取得患者的配合。3.评估患者的年龄、性别、病情、导尿目的、合作程度、膀胱充盈度、局部皮肤等。根据评估结果，选择合适的导尿管。4.导尿过程中严格遵循无菌技术操作原则，避免污染，保护患者隐私。5.为男性患者插尿管时,遇有阻力，特别是尿管经尿道内口、膜部、尿道外口的狭窄部、耻骨联合下方和前下方处的弯曲部时，嘱患者缓慢深呼吸，慢慢插入尿管。6.插入导尿管后注入10-15毫升无菌生理盐水，轻拉尿管以证实尿管固定稳妥。7.尿潴留患者一次导出尿量不超过1000毫升，以防出现虚脱和血尿。8.指导患者在留置尿管期间保证充足液体入量，预防发生感染和结石。9.嘱患者在留置尿管期间防止尿管打折、弯曲、受压、脱出等情况发生，保持通畅。10.嘱患者保持尿袋高度低于耻骨联合水平，防止逆行感染。 11.指导长期留置尿管的患者进行膀胱功能训练及骨盆底肌的锻炼，以增强控制排尿的能力。患者留置尿管期间，尿管要定时夹闭。 (三)结果标准 1.患者/家属知晓护士告知的事项，对操作满意。2.操作规范、安全，未给患者造成不必要的损伤。3.尿管与尿袋连接紧密，引流通畅，固定稳妥。 profile yongxing river level hydropower station pressure pipe pipeline plane Shang along Ridge is line layout, and slope surface contour close vertical, Guan Po with original ground line changes, used open type Ming tube, single tube joint water way, competent diameter 1.3M, long 931.00m, two root non-symmetric "Bu" type support tube, diameter 0.8M, single root long 8.3M. Competent to establish 12 town Pier, 107 buttress, telescopic section 11. Support Pier spacing 8M, side-sliding bearing. Town pier for the closed-end structure of gravity, base surface into bedrock, pipe excavation slope 1:0.75 with M5 grouted rubble slope protection, 0.3M, bottom side sewer, 0.25m wide, deep 0.3m,M5 grouted rubble masonry, set maintenance step ladder on the left side, 1.0M wide. Yongxinghe-? hydropower station penstock pipes arranged along the ridge line on the plane, and nearly vertical slope contour lines, Guan Po changes with the original ground line, with shallow backfill-pipe, single-pipe water supply, the competent 1.4m, long 1063.506m, two asymmetric "y" pipe, diameter 0.8M, single 10m. Competent to establish 12 town Pier, 8 expansion joint. Town pier for the closed-end structure of gravity, placed on soft rock base surface, pipe concrete C20 on a pedestal. Pipe trench excavation slope 1:0.75, after the installation of steel tube, compacted gravel backfill material to the surface, and 1:100 slope drainage to gutters. Gutter width 0.5M depth 0.5m,M5 grouted rubble masonry. 9.2 main engineering content this standard pressure pipe and the metal structure installation part main including Yunnan province tengchong County yongxing River primary and secondary hydropower station in the of pressure pipe and the power station metal structure, which level power station pressure pipe total about 562t (containing annex); II level power station pressure pipe about 733 t (containing annex); level power station metal structure about 52.5 t, containing discharge Gate 2 hole, rushed sand Gate 1 hole, water mouth work door and the stopped dirt gate the 1 hole, Qian pool work door and the stopped dirt gate the 1 hole; Secondary power station metal junction at about 19.5 t, containing sand Gate 1 hole, water inlet water gate and trash the 1 hole; their auxiliary hoist equipment and electrical 五、胃肠减压技术 (一)工作目标 遵医嘱为患者置胃管，患者能够了解有关知识并配合。 (二)工作规范要点 1.遵循查对制度，符合无菌技术、标准预防原则。2.告知患者/家属留置胃管的目的、注意事项，取得患者的配合。3.评估患者病情、意识状态、合作程度、患者鼻腔、有无分泌物阻塞、是否通畅，以及患者有无消化道狭窄或食道静脉曲张等，患者是否有以往插管的经验。根据评估结果选择合适的胃管。4.准确测量胃管插入的长度。?由耳垂到鼻尖再到剑突的距离。?前发际到剑突的距离(成人45-55厘米，儿童14-18厘米)。5.插管过程中指导患者配合技巧，安全顺利地插入胃管。6.昏迷患者应先将头向后仰，插至咽喉部(约15厘米)，再用一手托起头部，使下颌靠近胸骨柄，插至需要的长度。如插入不畅，应检查胃管是否盘在口腔中。插管过程中如发现呛咳、呼吸困难、紫绀等情况，表示误入气管，应立即拔出，休息片刻后重插。7.检查胃管是否在胃内。8.调整减压装置，将胃管与负压装置连接，妥善固定于床旁。9.告知患者留置胃肠减压管期间禁止饮水和进食，保持口腔清洁。10.妥善固定胃肠减压装置，防止变换体位时加重对咽部的刺激，以及胃管受压、脱出影响减压效果。11.观察引流物的颜色、性质、量，并记录24小时引流总量。12.留置胃管期间应当加强患者的口腔护理。13.胃肠减压期间，注意观察患者水电解质及胃肠功能恢复情况。14.及时发现并积极预防和处理与引流管相关的问题。 (三)结果标准 1.患者/家属能够知晓护士的告知事项，对服务满意。2.护士操作过程规范、准确、动作轻巧，患者配合。3.确保胃管于胃内，固定稳妥，保持有效胃肠减压。 六、灌肠技术 (一)工作目标 profile yongxing river level hydropower station pressure pipe pipeline plane Shang along Ridge is line layout, and slope surface contour close vertical, Guan Po with original ground line changes, used open type Ming tube, single tube joint water way, competent diameter 1.3M, long 931.00m, two root non-symmetric "Bu" type support tube, diameter 0.8M, single root long 8.3M. Competent to establish 12 town Pier, 107 buttress, telescopic section 11. Support Pier spacing 8M, side-sliding bearing. Town pier for the closed-end structure of gravity, base surface into bedrock, pipe excavation slope 1:0.75 with M5 grouted rubble slope protection, 0.3M, bottom side sewer, 0.25m wide, deep 0.3m,M5 grouted rubble masonry, set maintenance step ladder on the left side, 1.0M wide. Yongxinghe-? hydropower station penstock pipes arranged along the ridge line on the plane, and nearly vertical slope contour lines, Guan Po changes with the original ground line, with shallow backfill-pipe, single-pipe water supply, the competent 1.4m, long 1063.506m, two asymmetric "y" pipe, diameter 0.8M, single 10m. Competent to establish 12 town Pier, 8 expansion joint. Town pier for the closed-end structure of gravity, placed on soft rock base surface, pipe concrete C20 on a pedestal. Pipe trench excavation slope 1:0.75, after the installation of steel tube, compacted gravel backfill material to the surface, and 1:100 slope drainage to gutters. Gutter width 0.5M depth 0.5m,M5 grouted rubble masonry. 9.2 main engineering content this standard pressure pipe and the metal structure installation part main including Yunnan province tengchong County yongxing River primary and secondary hydropower station in the of pressure pipe and the power station metal structure, which level power station pressure pipe total about 562t (containing annex); II level power station pressure pipe about 733 t (containing annex); level power station metal structure about 52.5 t, containing discharge Gate 2 hole, rushed sand Gate 1 hole, water mouth work door and the stopped dirt gate the 1 hole, Qian pool work door and the stopped dirt gate the 1 hole; Secondary power station metal junction at about 19.5 t, containing sand Gate 1 hole, water inlet water gate and trash the 1 hole; their auxiliary hoist equipment and electrical 遵医嘱准确、安全地为患者灌肠;清洁肠道，解除便秘及肠胀气;降温;为诊断性检查及手术做准备。 (二)工作规范要点 1.评估患者的年龄、意识，有无烦躁、焦虑、及配合程度，有无灌肠禁忌症, 对急腹症、妊娠早期、消化道出血的患者禁止灌肠;肝性脑病患者禁用肥皂水灌肠;伤寒患者灌肠量不能超过500毫升，液面距肛门不得超过30厘米。2.告知患者及家属灌肠的目的及注意事项，指导患者配合。3.核对医嘱，做好准备，保证灌肠溶液的浓度、剂量、温度适宜。4.协助患者取仰卧位或左侧卧位，注意保暖，保护患者隐私。5.按照要求置入肛管，置入合适长度后固定肛管，使灌肠溶液缓慢流入并观察患者反应。6.灌肠完毕，嘱患者平卧，保持10-20分钟后再排便并观察大便性状。7.灌肠过程中，患者有便意，指导患者做深呼吸，同时适当调低灌肠筒的高度，减慢流速。嘱患者尽量坚持到有强烈的便意感。8.指导患者，如有心慌、气促等不适症状，立即平卧，避免发生意外。9.对患者进行降温灌肠时，灌肠后保留30分钟后再排便，排便后30分钟测体温。10.清洁灌肠应反复多次，首先用肥皂水，再用生理盐水，直至排出液澄清、无粪便为止。11.操作结束后，做好肛周清洁，整理床单位。12.观察排出大便的量、颜色、性质及排便次数。 (三)结果标准 1.患者/家属能够知晓护士的告知事项，对服务满意。2.护士操作过程规范、准确。3.患者排空大便及肠道内积气，无并发症发生。 七、氧气吸入技术 (一)工作目标 遵医嘱给予患者氧气治疗，改善患者缺氧状态，确保用氧安全。 (二)工作规范要点 1.评估患者病情、呼吸状态、缺氧程度、鼻腔情况。 2.告知患者安全用氧的重要性，做好四防，即防震、防火、防热、防油。告知患profile yongxing river level hydropower station pressure pipe pipeline plane Shang along Ridge is line layout, and slope surface contour close vertical, Guan Po with original ground line changes, used open type Ming tube, single tube joint water way, competent diameter 1.3M, long 931.00m, two root non-symmetric "Bu" type support tube, diameter 0.8M, single root long 8.3M. Competent to establish 12 town Pier, 107 buttress, telescopic section 11. Support Pier spacing 8M, side-sliding bearing. Town pier for the closed-end structure of gravity, base surface into bedrock, pipe excavation slope 1:0.75 with M5 grouted rubble slope protection, 0.3M, bottom side sewer, 0.25m wide, deep 0.3m,M5 grouted rubble masonry, set maintenance step ladder on the left side, 1.0M wide. Yongxinghe-? hydropower station penstock pipes arranged along the ridge line on the plane, and nearly vertical slope contour lines, Guan Po changes with the original ground line, with shallow backfill-pipe, single-pipe water supply, the competent 1.4m, long 1063.506m, two asymmetric "y" pipe, diameter 0.8M, single 10m. Competent to establish 12 town Pier, 8 expansion joint. Town pier for the closed-end structure of gravity, placed on soft rock base surface, pipe concrete C20 on a pedestal. Pipe trench excavation slope 1:0.75, after the installation of steel tube, compacted gravel backfill material to the surface, and 1:100 slope drainage to gutters. Gutter width 0.5M depth 0.5m,M5 grouted rubble masonry. 9.2 main engineering content this standard pressure pipe and the metal structure installation part main including Yunnan province tengchong County yongxing River primary and secondary hydropower station in the of pressure pipe and the power station metal structure, which level power station pressure pipe total about 562t (containing annex); II level power station pressure pipe about 733 t (containing annex); level power station metal structure about 52.5 t, containing discharge Gate 2 hole, rushed sand Gate 1 hole, water mouth work door and the stopped dirt gate the 1 hole, Qian pool work door and the stopped dirt gate the 1 hole; Secondary power station metal junction at about 19.5 t, containing sand Gate 1 hole, water inlet water gate and trash the 1 hole; their auxiliary hoist equipment and electrical 者不能自行调节氧流量。 3.根据评估结果，选择合适的氧疗方法。 ?鼻导管或鼻塞:适用于低流量吸氧、有二氧化碳潴留的患者。 ? 面罩:?普通面罩:适用于高流量吸氧，无二氧化碳潴留的患者。?储氧面罩:可以提供较高的吸氧浓度。?Venturi(文丘里)面罩:可以提供控制性氧治疗。 ? 氧气帐或头罩:主要适用于儿童。 4.遵医嘱根据病情调节合适的氧流量。5.使用氧气时，应先调节氧流量后应用。停用氧气时，应先拔出导管，再关闭氧气开。6.密切观察患者氧气治疗的效果。7.严格遵守操作，注意用氧安全。 (三)结果标准 1.患者/家属能够知晓护士的告知事项，对服务满意。2.患者的缺氧症状得到改善。 八、雾化吸人疗法 (一)工作目标 遵医嘱准确为患者提供剂量准确、安全、雾量适宜的雾化吸入。 (二)工作规范要点 1.遵循查对制度，符合标准预防、安全给药的原则。 2.了解患者过敏史、用药史、用药目的、患者呼吸状况及配合能力。3.协助患者取合适体位。告知患者治疗目的、药物名称，指导患者配合。4.按雾化吸入的目的和要求准备药物和雾化装置，并检查装置性能。5.给患者戴上面罩或口含嘴，指导患者吸入。气管切开的患者，可直接将面罩置于气管切开造口处。6.观察患者吸入药物后的反应及效果。7.雾化吸入的面罩、口含嘴一人一套，防止交叉感染。 (三)结果标准 1.患者/家属能够知晓护士的告知事项，对服务满意。2.操作过程规范、安全，达到预期目的。 profile yongxing river level hydropower station pressure pipe pipeline plane Shang along Ridge is line layout, and slope surface contour close vertical, Guan Po with original ground line changes, used open type Ming tube, single tube joint water way, competent diameter 1.3M, long 931.00m, two root non-symmetric "Bu" type support tube, diameter 0.8M, single root long 8.3M. Competent to establish 12 town Pier, 107 buttress, telescopic section 11. Support Pier spacing 8M, side-sliding bearing. Town pier for the closed-end structure of gravity, base surface into bedrock, pipe excavation slope 1:0.75 with M5 grouted rubble slope protection, 0.3M, bottom side sewer, 0.25m wide, deep 0.3m,M5 grouted rubble masonry, set maintenance step ladder on the left side, 1.0M wide. Yongxinghe-? hydropower station penstock pipes arranged along the ridge line on the plane, and nearly vertical slope contour lines, Guan Po changes with the original ground line, with shallow backfill-pipe, single-pipe water supply, the competent 1.4m, long 1063.506m, two asymmetric "y" pipe, diameter 0.8M, single 10m. Competent to establish 12 town Pier, 8 expansion joint. Town pier for the closed-end structure of gravity, placed on soft rock base surface, pipe concrete C20 on a pedestal. Pipe trench excavation slope 1:0.75, after the installation of steel tube, compacted gravel backfill material to the surface, and 1:100 slope drainage to gutters. Gutter width 0.5M depth 0.5m,M5 grouted rubble masonry. 9.2 main engineering content this standard pressure pipe and the metal structure installation part main including Yunnan province tengchong County yongxing River primary and secondary hydropower station in the of pressure pipe and the power station metal structure, which level power station pressure pipe total about 562t (containing annex); II level power station pressure pipe about 733 t (containing annex); level power station metal structure about 52.5 t, containing discharge Gate 2 hole, rushed sand Gate 1 hole, water mouth work door and the stopped dirt gate the 1 hole, Qian pool work door and the stopped dirt gate the 1 hole; Secondary power station metal junction at about 19.5 t, containing sand Gate 1 hole, water inlet water gate and trash the 1 hole; their auxiliary hoist equipment and electrical 九、血糖监测 (一)工作目标 遵医嘱准确测量患者血糖，为治疗提供依据。 (二)工作规范要点 1.遵循查对制度，符合无菌技术、标准预防原则。2.告知患者监测血糖的目的，做好准备。评估患者穿刺部位皮肤状况。3.确认血糖仪的号码与试纸号码一致，正确安装采血针，确认监测血糖的时间(如空腹、餐后2小时等)。4.确认患者手指酒精干透后实施采血，采血量充足，应使试纸试区完全变成红色。5.指导患者穿刺后按压1-2分钟。6.将结果告诉患者/家属，并通知医师。7.对需要长期监测血糖的患者，穿刺部位应轮换，并指导患者血糖监测的方法。 (三)结果标准 1.患者/家属能够知晓护士的告知事项，对服务满意。2.操作过程规范，结果准确。 十、口服给药技术 (一)工作目标 遵医嘱正确为患者实施口服给药，并观察药物作用。 (二)工作规范要点 1.遵循标准预防、安全给药原则。2.评估患者病情、过敏史、用药史、不良反应史。如有疑问应核对无误后方可给药。3.告知患者/家属药物相关注意事项，取得患者配合。4.严格遵循查对制度，了解患者所服药物的作用、不良反应以及某些药物服用的特殊要求5.协助患者服药，为鼻饲患者给药时，应当将药物研碎溶解后由胃管注6.若患者因故暂不能服药者，暂不发药，并做好交班。7.对服用强心甙类药物的患者,服药前应当先测脉搏、心率，注意其节律变化，如脉率低于60次/分钟或者节律不齐时，不可以服用。8.观察患者服药效果及不良反应。如有异常情况及时与医师沟通。 profile yongxing river level hydropower station pressure pipe pipeline plane Shang along Ridge is line layout, and slope surface contour close vertical, Guan Po with original ground line changes, used open type Ming tube, single tube joint water way, competent diameter 1.3M, long 931.00m, two root non-symmetric "Bu" type support tube, diameter 0.8M, single root long 8.3M. Competent to establish 12 town Pier, 107 buttress, telescopic section 11. Support Pier spacing 8M, side-sliding bearing. Town pier for the closed-end structure of gravity, base surface into bedrock, pipe excavation slope 1:0.75 with M5 grouted rubble slope protection, 0.3M, bottom side sewer, 0.25m wide, deep 0.3m,M5 grouted rubble masonry, set maintenance step ladder on the left side, 1.0M wide. Yongxinghe-? hydropower station penstock pipes arranged along the ridge line on the plane, and nearly vertical slope contour lines, Guan Po changes with the original ground line, with shallow backfill-pipe, single-pipe water supply, the competent 1.4m, long 1063.506m, two asymmetric "y" pipe, diameter 0.8M, single 10m. Competent to establish 12 town Pier, 8 expansion joint. Town pier for the closed-end structure of gravity, placed on soft rock base surface, pipe concrete C20 on a pedestal. Pipe trench excavation slope 1:0.75, after the installation of steel tube, compacted gravel backfill material to the surface, and 1:100 slope drainage to gutters. Gutter width 0.5M depth 0.5m,M5 grouted rubble masonry. 9.2 main engineering content this standard pressure pipe and the metal structure installation part main including Yunnan province tengchong County yongxing River primary and secondary hydropower station in the of pressure pipe and the power station metal structure, which level power station pressure pipe total about 562t (containing annex); II level power station pressure pipe about 733 t (containing annex); level power station metal structure about 52.5 t, containing discharge Gate 2 hole, rushed sand Gate 1 hole, water mouth work door and the stopped dirt gate the 1 hole, Qian pool work door and the stopped dirt gate the 1 hole; Secondary power station metal junction at about 19.5 t, containing sand Gate 1 hole, water inlet water gate and trash the 1 hole; their auxiliary hoist equipment and electrical (三)结果标准 1.患者/家属知晓护士的告知事项，对服务满意。2.帮助患者正确服用药物。3.及时发现不良反应，采取适当措施。 十一、密闭式输液技术 (一)工作目标 遵医嘱准确为患者静脉输液，操作规范，确保患者安全。 (二)工作规范要点 1.遵循查对制度，符合无菌技术、标准预防、安全给药原则。2.告知患者，做好准备。评估患者过敏史、用药史及穿刺部位的皮肤、血管状况。3.选择合适的静脉。老年、长期卧床、手术患者避免选择下肢浅静脉穿4.告知患者输注药物名称及注意事项。5.在静脉配制中心或治疗室进行配药，配制化疗和毒性药物时应在安全的环境下配置。药物要现用现配，注意配伍禁忌。6.协助患者取舒适体位，调节输液速度。根据病情、年龄、药物性质调节速度，嘱患者不要自行调节输液速度。7.观察患者输液部位状况及有无输液反应，及时处理输液故障，对于特殊药物、特殊患者应密切巡视。8.拔除输液后，嘱咐患者按压穿刺点5,10分钟，勿揉，凝血差的患者适当延长按压时间。 (三)结果标准 1.患者/家属能够知晓护士的告知事项，对服务满意。2.操作过程规范、准确。3.及时发现不良反应，采取适当措施。 十二、密闭式静脉输血技术 (一)工作目标 遵医嘱为患者正确安全地静脉输血，操作规范，及时发现、处理并发症。 (二)工作规范要点 1.遵循查对制度，符合无菌技术、标准预防、安全输血原则。2.告知患者，做好准备。评估患者生命体征、输血史、输血目的、合作能力、心理状态和血管状况。profile yongxing river level hydropower station pressure pipe pipeline plane Shang along Ridge is line layout, and slope surface contour close vertical, Guan Po with original ground line changes, used open type Ming tube, single tube joint water way, competent diameter 1.3M, long 931.00m, two root non-symmetric "Bu" type support tube, diameter 0.8M, single root long 8.3M. Competent to establish 12 town Pier, 107 buttress, telescopic section 11. Support Pier spacing 8M, side-sliding bearing. Town pier for the closed-end structure of gravity, base surface into bedrock, pipe excavation slope 1:0.75 with M5 grouted rubble slope protection, 0.3M, bottom side sewer, 0.25m wide, deep 0.3m,M5 grouted rubble masonry, set maintenance step ladder on the left side, 1.0M wide. Yongxinghe-? hydropower station penstock pipes arranged along the ridge line on the plane, and nearly vertical slope contour lines, Guan Po changes with the original ground line, with shallow backfill-pipe, single-pipe water supply, the competent 1.4m, long 1063.506m, two asymmetric "y" pipe, diameter 0.8M, single 10m. Competent to establish 12 town Pier, 8 expansion joint. Town pier for the closed-end structure of gravity, placed on soft rock base surface, pipe concrete C20 on a pedestal. Pipe trench excavation slope 1:0.75, after the installation of steel tube, compacted gravel backfill material to the surface, and 1:100 slope drainage to gutters. Gutter width 0.5M depth 0.5m,M5 grouted rubble masonry. 9.2 main engineering content this standard pressure pipe and the metal structure installation part main including Yunnan province tengchong County yongxing River primary and secondary hydropower station in the of pressure pipe and the power station metal structure, which level power station pressure pipe total about 562t (containing annex); II level power station pressure pipe about 733 t (containing annex); level power station metal structure about 52.5 t, containing discharge Gate 2 hole, rushed sand Gate 1 hole, water mouth work door and the stopped dirt gate the 1 hole, Qian pool work door and the stopped dirt gate the 1 hole; Secondary power station metal junction at about 19.5 t, containing sand Gate 1 hole, water inlet water gate and trash the 1 hole; their auxiliary hoist equipment and electrical 告知患者输血的目的、注意事项和不良反应。3.严格执行查对制度。输血核对必须双人核对，包括取血时核对，输血前、中、后核对和发生输血反应时的核对。核对内容包括:患者姓名、性别、床号、住院号、血袋号、血型、血液数量、血液种类、交叉试验结果、血液有效期、血袋完整性和血液的外观。发生输血反应时核对用血申请单、血袋标签、交叉配血试验记录及受血者与供血者的血型。4.建立合适的静脉通道，密切观察患者，出现不良反应，立即停止输血并通知医师及时处理。5.血制品应在产品规定的时间内输完，输入两个以上供血者的血液时，应在两份血液之间输入0.9%氯化钠注射液。6.开始输血时速度宜慢，观察15分钟，无不良反应后，将滴速调节至要求速度。7.输血完毕，贮血袋在4?冰箱保存24小时。 (三)结果标准 1.患者/家属能够知晓护士的告知事项，对服务满意。2.护士操作过程规范、准确。3.及时发现输血反应，妥善处理。 十三、静脉留置针技术 (一)工作目标 正确使用留置针建立静脉通道，减少患者反复穿刺的痛苦。 (二)工作规范要点 1.遵循查对制度，符合无菌技术、标准预防原则。2.告知患者留置针的作用、注意事项及可能出现的并发症。3.评估患者病情、治疗、用药以及穿刺部位的皮肤和血管状况。4.选择弹性适当血管穿刺，正确实施输液前后留置针的封管及护理。5.严密观察留置针有无脱出、断裂，局部有无红肿热痛等静脉炎表现，及时处理置管相关并发症。6.嘱患者穿刺处勿沾水，敷料潮湿应随时更换，留置针侧肢体避免剧烈活动或长时间下垂等。7.每次输液前后应当检查患者穿刺部位及静脉走向有无红、肿，询问患者有关情况，发现异常时及时拔除导管，给予处理。 (三)结果标准 profile yongxing river level hydropower station pressure pipe pipeline plane Shang along Ridge is line layout, and slope surface contour close vertical, Guan Po with original ground line changes, used open type Ming tube, single tube joint water way, competent diameter 1.3M, long 931.00m, two root non-symmetric "Bu" type support tube, diameter 0.8M, single root long 8.3M. Competent to establish 12 town Pier, 107 buttress, telescopic section 11. Support Pier spacing 8M, side-sliding bearing. Town pier for the closed-end structure of gravity, base surface into bedrock, pipe excavation slope 1:0.75 with M5 grouted rubble slope protection, 0.3M, bottom side sewer, 0.25m wide, deep 0.3m,M5 grouted rubble masonry, set maintenance step ladder on the left side, 1.0M wide. Yongxinghe-? hydropower station penstock pipes arranged along the ridge line on the plane, and nearly vertical slope contour lines, Guan Po changes with the original ground line, with shallow backfill-pipe, single-pipe water supply, the competent 1.4m, long 1063.506m, two asymmetric "y" pipe, diameter 0.8M, single 10m. Competent to establish 12 town Pier, 8 expansion joint. Town pier for the closed-end structure of gravity, placed on soft rock base surface, pipe concrete C20 on a pedestal. Pipe trench excavation slope 1:0.75, after the installation of steel tube, compacted gravel backfill material to the surface, and 1:100 slope drainage to gutters. Gutter width 0.5M depth 0.5m,M5 grouted rubble masonry. 9.2 main engineering content this standard pressure pipe and the metal structure installation part main including Yunnan province tengchong County yongxing River primary and secondary hydropower station in the of pressure pipe and the power station metal structure, which level power station pressure pipe total about 562t (containing annex); II level power station pressure pipe about 733 t (containing annex); level power station metal structure about 52.5 t, containing discharge Gate 2 hole, rushed sand Gate 1 hole, water mouth work door and the stopped dirt gate the 1 hole, Qian pool work door and the stopped dirt gate the 1 hole; Secondary power station metal junction at about 19.5 t, containing sand Gate 1 hole, water inlet water gate and trash the 1 hole; their auxiliary hoist equipment and electrical 1.患者/家属能够知晓护士的告知事项，对服务满意。2.护士操作过程规范、准确。 十四、静脉血标本的采集技术 (一)工作目标 遵医嘱准确为患者采集静脉血标本，操作规范，确保患者安全。 (二)工作规范要点 1.遵循查对制度，符合无菌技术，标准预防原则。2.评估患者的病情、静脉情况，准备用物。若患者正在进行静脉输液、输血，不宜在同侧手臂采血。3.告知患者/家属采血的目的及采血前后的注意事项。4.协助患者，取舒适体位。5.采血后指导患者压穿刺点5,10分钟，勿揉，凝血机制差的患者适当延长按压时间。6.按要求正确处理血标本，尽快送检。 (三)结果标准 1.患者/家属能够知晓护士的告知事项，对服务满意。2.护士操作过程规范、准确。3.采取标本方法正确，标本不发生溶血，抗凝标本无凝血，符合检验要求。 十五、静脉注射技术 (一)工作目标 遵医嘱准确为患者静脉注射，操作规范，确保患者安全。 (二)工作规范要点 1.遵循查对制度，符合无菌技术、标准预防、安全给药原则。2.告知患者，做好准备。评估患者过敏史、用药史，以及穿刺部位的皮肤、血管状况。3.告知患者输注药物名称及注意事项。4.在静脉配制中心或治疗室进行配药，药物要现用现配，注意配伍禁忌。5.协助患者取舒适体位。6.根据病情及药物性质掌握注入药物的速度，必要时使用微量注射泵。7.静脉注射过程中，观察局部组织有无肿胀、严防药液渗漏，观察病情变化。 8.拔针后，嘱咐患者按压穿刺点5,10分钟，勿揉，凝血机制差的患者适当延长profile yongxing river level hydropower station pressure pipe pipeline plane Shang along Ridge is line layout, and slope surface contour close vertical, Guan Po with original ground line changes, used open type Ming tube, single tube joint water way, competent diameter 1.3M, long 931.00m, two root non-symmetric "Bu" type support tube, diameter 0.8M, single root long 8.3M. Competent to establish 12 town Pier, 107 buttress, telescopic section 11. Support Pier spacing 8M, side-sliding bearing. Town pier for the closed-end structure of gravity, base surface into bedrock, pipe excavation slope 1:0.75 with M5 grouted rubble slope protection, 0.3M, bottom side sewer, 0.25m wide, deep 0.3m,M5 grouted rubble masonry, set maintenance step ladder on the left side, 1.0M wide. Yongxinghe-? hydropower station penstock pipes arranged along the ridge line on the plane, and nearly vertical slope contour lines, Guan Po changes with the original ground line, with shallow backfill-pipe, single-pipe water supply, the competent 1.4m, long 1063.506m, two asymmetric "y" pipe, diameter 0.8M, single 10m. Competent to establish 12 town Pier, 8 expansion joint. Town pier for the closed-end structure of gravity, placed on soft rock base surface, pipe concrete C20 on a pedestal. Pipe trench excavation slope 1:0.75, after the installation of steel tube, compacted gravel backfill material to the surface, and 1:100 slope drainage to gutters. Gutter width 0.5M depth 0.5m,M5 grouted rubble masonry. 9.2 main engineering content this standard pressure pipe and the metal structure installation part main including Yunnan province tengchong County yongxing River primary and secondary hydropower station in the of pressure pipe and the power station metal structure, which level power station pressure pipe total about 562t (containing annex); II level power station pressure pipe about 733 t (containing annex); level power station metal structure about 52.5 t, containing discharge Gate 2 hole, rushed sand Gate 1 hole, water mouth work door and the stopped dirt gate the 1 hole, Qian pool work door and the stopped dirt gate the 1 hole; Secondary power station metal junction at about 19.5 t, containing sand Gate 1 hole, water inlet water gate and trash the 1 hole; their auxiliary hoist equipment and electrical 按压时间。 (三)结果标准 1.患者/家属知晓护士的告知事项，对服务满意。2.护士操作过程规范、准确。 十六、肌内注射技术 (一)工作目标 遵医嘱准确为患者肌内注射，操作规范，确保患者安全。 (二)工作规范要点 1.遵循查对制度，符合无菌技术、标准预防、安全给药原则。2.告知患者，做好准备。评估患者病情、过敏史、用药史，以及注射部位皮肤情况。3.告知患者药物名称及注意事项，取得患者配合。4.选择合适的注射器及注射部位，需长期注射者，有地更换注射部位。 5.协助患者采取适当体位，患者注射时勿紧张，肌肉放松。6.注射中、注射后观察患者反应、用药效果及不良反应。7.需要两种药物同时注射时，应注意配伍禁忌。 (三)结果标准 1.患者/家属知晓护士的告知事项，对服务满意。2.护士操作过程规范、准确。 十七、皮内注射技术 (一)工作目标 遵医嘱准确为患者进行皮内注射;确保患者安全。 (二)工作规范要点 1.遵循查对制度，符合无菌技术、标准预防、安全给药原则。2.告知患者，做好准备。评估患者病情、过敏史、用药史，以及注射部位皮肤情况。3.告知患者药物名称及注意事项，取得患者配合。4.备好相应的抢救药物与设备并处于备用状态。5.皮试药液要现用现配，剂量准确。6.告知患者皮试后20分钟内不要远离病房，不要按揉注射部位。7.密切观察病情，及时处理各种过敏反应。8.正确判断试验结果。对皮试结果阳性者，应标记，并将结果告知医师、患者及家属。 profile yongxing river level hydropower station pressure pipe pipeline plane Shang along Ridge is line layout, and slope surface contour close vertical, Guan Po with original ground line changes, used open type Ming tube, single tube joint water way, competent diameter 1.3M, long 931.00m, two root non-symmetric "Bu" type support tube, diameter 0.8M, single root long 8.3M. Competent to establish 12 town Pier, 107 buttress, telescopic section 11. Support Pier spacing 8M, side-sliding bearing. Town pier for the closed-end structure of gravity, base surface into bedrock, pipe excavation slope 1:0.75 with M5 grouted rubble slope protection, 0.3M, bottom side sewer, 0.25m wide, deep 0.3m,M5 grouted rubble masonry, set maintenance step ladder on the left side, 1.0M wide. Yongxinghe-? hydropower station penstock pipes arranged along the ridge line on the plane, and nearly vertical slope contour lines, Guan Po changes with the original ground line, with shallow backfill-pipe, single-pipe water supply, the competent 1.4m, long 1063.506m, two asymmetric "y" pipe, diameter 0.8M, single 10m. Competent to establish 12 town Pier, 8 expansion joint. Town pier for the closed-end structure of gravity, placed on soft rock base surface, pipe concrete C20 on a pedestal. Pipe trench excavation slope 1:0.75, after the installation of steel tube, compacted gravel backfill material to the surface, and 1:100 slope drainage to gutters. Gutter width 0.5M depth 0.5m,M5 grouted rubble masonry. 9.2 main engineering content this standard pressure pipe and the metal structure installation part main including Yunnan province tengchong County yongxing River primary and secondary hydropower station in the of pressure pipe and the power station metal structure, which level power station pressure pipe total about 562t (containing annex); II level power station pressure pipe about 733 t (containing annex); level power station metal structure about 52.5 t, containing discharge Gate 2 hole, rushed sand Gate 1 hole, water mouth work door and the stopped dirt gate the 1 hole, Qian pool work door and the stopped dirt gate the 1 hole; Secondary power station metal junction at about 19.5 t, containing sand Gate 1 hole, water inlet water gate and trash the 1 hole; their auxiliary hoist equipment and electrical (三)结果标准 1.患者/家属知晓护士的告知事项，对服务满意。2.护士操作过程规范、准确。 十八、皮下注射技术 (一)工作目标 遵医嘱准确为患者皮下注射，操作规范，确保患者安全。 (二)工作规范要点 1.遵循查对制度，符合无菌技术、标准预防、安全给药原则。2.告知患者，做好准备。评估患者病情、过敏史、用药史，以及注射部位皮肤情况。3.告知患者药物名称及注意事项，取得患者配合。 4.选择合适的注射器及注射部位。需长期注射者，有计划地更换注射部位。 5.注射中、注射后观察患者反应、用药效果及不良反应。6.皮下注射胰岛素时，嘱患者注射后15分钟开始进食，避免不必要的活动，注意安全。 (三)结果标准 1.患者/家属知晓护士告知的事项，对服务满意。2.护士操作过程规范、准确。 十九、物理降温法 (一)工作目标 遵医嘱安全地为患者实施物理降温，减轻患者不适。 (二)工作规范要点 1.告知患者，做好准备。评估患者病情、意识、局部组织灌注情况、皮肤情况、配合程度、有无酒精过敏史。2.告知患者物理降温的目的及注意事项。3.嘱患者在高热期间摄入足够的水分。4.操作过程中，保护患者的隐私。5.实施物理降温时应观察局部血液循环和体温变化情况。重点观察患者皮肤状况，如患者发生局部皮肤苍白、青紫或者有麻木感时，应立即停止使用，防止冻伤发生。 6.物理降温时,应当避开患者的枕后、耳廓、心前区、腹部、阴囊及足底部位 。7.记录患者的体温和病情变化，及时与医师沟通，严格交接班。 profile yongxing river level hydropower station pressure pipe pipeline plane Shang along Ridge is line layout, and slope surface contour close vertical, Guan Po with original ground line changes, used open type Ming tube, single tube joint water way, competent diameter 1.3M, long 931.00m, two root non-symmetric "Bu" type support tube, diameter 0.8M, single root long 8.3M. Competent to establish 12 town Pier, 107 buttress, telescopic section 11. Support Pier spacing 8M, side-sliding bearing. Town pier for the closed-end structure of gravity, base surface into bedrock, pipe excavation slope 1:0.75 with M5 grouted rubble slope protection, 0.3M, bottom side sewer, 0.25m wide, deep 0.3m,M5 grouted rubble masonry, set maintenance step ladder on the left side, 1.0M wide. Yongxinghe-? hydropower station penstock pipes arranged along the ridge line on the plane, and nearly vertical slope contour lines, Guan Po changes with the original ground line, with shallow backfill-pipe, single-pipe water supply, the competent 1.4m, long 1063.506m, two asymmetric "y" pipe, diameter 0.8M, single 10m. Competent to establish 12 town Pier, 8 expansion joint. Town pier for the closed-end structure of gravity, placed on soft rock base surface, pipe concrete C20 on a pedestal. Pipe trench excavation slope 1:0.75, after the installation of steel tube, compacted gravel backfill material to the surface, and 1:100 slope drainage to gutters. Gutter width 0.5M depth 0.5m,M5 grouted rubble masonry. 9.2 main engineering content this standard pressure pipe and the metal structure installation part main including Yunnan province tengchong County yongxing River primary and secondary hydropower station in the of pressure pipe and the power station metal structure, which level power station pressure pipe total about 562t (containing annex); II level power station pressure pipe about 733 t (containing annex); level power station metal structure about 52.5 t, containing discharge Gate 2 hole, rushed sand Gate 1 hole, water mouth work door and the stopped dirt gate the 1 hole, Qian pool work door and the stopped dirt gate the 1 hole; Secondary power station metal junction at about 19.5 t, containing sand Gate 1 hole, water inlet water gate and trash the 1 hole; their auxiliary hoist equipment and electrical (三)结果标准 1.患者/家属能够知晓护士的告知事项，对服务满意。2.护士操作过程规范。 二十、经鼻/口腔吸痰法 (一)工作目标 保持患者呼吸道通畅，确保患者安全。 (二)工作规范要点 1.遵循无菌技术、标准预防、消毒隔离原则。 2.告知患者，做好准备，如有义齿应取出。 3.评估患者生命体征、病情、意识状态、合作程度、氧疗情况、SpO2、咳嗽能力、痰液的颜色、量和粘稠度、按需吸痰。 4.选择粗细、长短、质地适宜的吸痰管。吸痰管应一用一换。 5.吸痰前后给予高流量氧气吸入2分钟。 6.调节合适的吸痰压力，成人为,200毫米汞柱。 7.吸痰时应旋转上提，自深部向上吸净痰液，避免反复上提。每次吸痰时间小于15秒，间歇3-5分钟。 8.吸痰过程中密切观察患者的痰液情况、心率和SpO2，当出现心率下降或SpO2低于90%时，立即停止吸痰，待心率和SpO2恢复后再吸，判断吸痰效果。 9.吸痰过程中应鼓励患者咳嗽。 (三)结果标准 1.清醒的患者能够知晓护士的告知事项，并配合操作。2.护士操作过程规范、安全、有效。 二十一、经气管插管/气管切开吸痰法 (一)工作目标 保持患者呼吸道通畅，确保患者安全。 (二)工作规范要点 1.遵循无菌技术、标准预防、消毒隔离原则。2.告知患者，做好准备。3.评估患者生命体征、病情、意识状态、合作程度、呼吸机的参数、SpO2、气道压力、痰液的颜色、量和粘稠度，按需吸痰。4.选择粗细、长短、质地适宜的吸痰管。吸profile yongxing river level hydropower station pressure pipe pipeline plane Shang along Ridge is line layout, and slope surface contour close vertical, Guan Po with original ground line changes, used open type Ming tube, single tube joint water way, competent diameter 1.3M, long 931.00m, two root non-symmetric "Bu" type support tube, diameter 0.8M, single root long 8.3M. Competent to establish 12 town Pier, 107 buttress, telescopic section 11. Support Pier spacing 8M, side-sliding bearing. Town pier for the closed-end structure of gravity, base surface into bedrock, pipe excavation slope 1:0.75 with M5 grouted rubble slope protection, 0.3M, bottom side sewer, 0.25m wide, deep 0.3m,M5 grouted rubble masonry, set maintenance step ladder on the left side, 1.0M wide. Yongxinghe-? hydropower station penstock pipes arranged along the ridge line on the plane, and nearly vertical slope contour lines, Guan Po changes with the original ground line, with shallow backfill-pipe, single-pipe water supply, the competent 1.4m, long 1063.506m, two asymmetric "y" pipe, diameter 0.8M, single 10m. Competent to establish 12 town Pier, 8 expansion joint. Town pier for the closed-end structure of gravity, placed on soft rock base surface, pipe concrete C20 on a pedestal. Pipe trench excavation slope 1:0.75, after the installation of steel tube, compacted gravel backfill material to the surface, and 1:100 slope drainage to gutters. Gutter width 0.5M depth 0.5m,M5 grouted rubble masonry. 9.2 main engineering content this standard pressure pipe and the metal structure installation part main including Yunnan province tengchong County yongxing River primary and secondary hydropower station in the of pressure pipe and the power station metal structure, which level power station pressure pipe total about 562t (containing annex); II level power station pressure pipe about 733 t (containing annex); level power station metal structure about 52.5 t, containing discharge Gate 2 hole, rushed sand Gate 1 hole, water mouth work door and the stopped dirt gate the 1 hole, Qian pool work door and the stopped dirt gate the 1 hole; Secondary power station metal junction at about 19.5 t, containing sand Gate 1 hole, water inlet water gate and trash the 1 hole; their auxiliary hoist equipment and electrical 痰管应一用一换。5.吸痰前后给予100%的氧气吸入2分钟。6.调节合适的吸痰压力，成人为,200毫米汞柱。7.吸痰过程中密切观察患者的痰液情况、心率和SpO2，当出现心率下降或SpO2低于90%时，立即停止吸痰，待心率和SpO2恢复后再吸。判断吸痰效果。8.吸痰过程中应鼓励患者咳嗽。 (三)结果标准 1.清醒的患者能够知晓护士的告知事项，并配合操作。2.护士操作过程规范、安全、有效。 二十二、心电监测技术 (一)工作目标 遵医嘱正确监测患者心率、心律变化，动态评价病情变化，为临床治疗提供依据。 (二)工作规范要点 1.评估患者病情、意识状态、皮肤状况。2.对清醒患者，告知监测目的，取得患者合作。3.正确选择导联，设置报警界限，不能关闭报警声音。4.嘱患者不要自行移动或者摘除电极片、避免在监测仪附近使用手机，以免干扰监测波形。5.密切观察心电图波形，及时处理异常情况。8.嘱患者电极片处皮肤出现瘙痒、疼痛等情况时，及时告诉医护人员。9.定时更换电极片和电极片位置。10.停用时，先向患者说明，取得合作后关机，断开电源。 (三)结果标准1.患者/家属能够知晓护士的告知事项，对服务满意。2.护士操作规范。 二十三、输液泵/微量注射泵的使用技术 (一)工作目标 遵医嘱正确使用输液泵/微量注射泵。 (二)工作规范要点 1.遵循查对制度，符合无菌技术、标准预防、安全给药原则。2.告知患者，做好准备。评估患者生命体征、年龄、病情、心功能等情况及药物的作用和注意事项、profile yongxing river level hydropower station pressure pipe pipeline plane Shang along Ridge is line layout, and slope surface contour close vertical, Guan Po with original ground line changes, used open type Ming tube, single tube joint water way, competent diameter 1.3M, long 931.00m, two root non-symmetric "Bu" type support tube, diameter 0.8M, single root long 8.3M. Competent to establish 12 town Pier, 107 buttress, telescopic section 11. Support Pier spacing 8M, side-sliding bearing. Town pier for the closed-end structure of gravity, base surface into bedrock, pipe excavation slope 1:0.75 with M5 grouted rubble slope protection, 0.3M, bottom side sewer, 0.25m wide, deep 0.3m,M5 grouted rubble masonry, set maintenance step ladder on the left side, 1.0M wide. Yongxinghe-? hydropower station penstock pipes arranged along the ridge line on the plane, and nearly vertical slope contour lines, Guan Po changes with the original ground line, with shallow backfill-pipe, single-pipe water supply, the competent 1.4m, long 1063.506m, two asymmetric "y" pipe, diameter 0.8M, single 10m. Competent to establish 12 town Pier, 8 expansion joint. Town pier for the closed-end structure of gravity, placed on soft rock base surface, pipe concrete C20 on a pedestal. Pipe trench excavation slope 1:0.75, after the installation of steel tube, compacted gravel backfill material to the surface, and 1:100 slope drainage to gutters. Gutter width 0.5M depth 0.5m,M5 grouted rubble masonry. 9.2 main engineering content this standard pressure pipe and the metal structure installation part main including Yunnan province tengchong County yongxing River primary and secondary hydropower station in the of pressure pipe and the power station metal structure, which level power station pressure pipe total about 562t (containing annex); II level power station pressure pipe about 733 t (containing annex); level power station metal structure about 52.5 t, containing discharge Gate 2 hole, rushed sand Gate 1 hole, water mouth work door and the stopped dirt gate the 1 hole, Qian pool work door and the stopped dirt gate the 1 hole; Secondary power station metal junction at about 19.5 t, containing sand Gate 1 hole, water inlet water gate and trash the 1 hole; their auxiliary hoist equipment and electrical 患者的合作程度、输注通路的通畅情况及有无药物配伍禁忌。3.告知患者输注药物名称及注意事项。4.告知患者使用输液泵/微量注射泵的目的、注意事项及使用过程中不可自行调节。5.妥善固定输液泵/微量注射泵，按需设定参数。6.随时查看工作状态指示灯。7.观察患者输液部位状况，观察用药效果和不良反应，发生异常情况及时与医师沟通并处理。 (三)结果标准 1.患者/家属能够知晓护士的告知事项，对服务满意。2.护士操作规范。 profile yongxing river level hydropower station pressure pipe pipeline plane Shang along Ridge is line layout, and slope surface contour close vertical, Guan Po with original ground line changes, used open type Ming tube, single tube joint water way, competent diameter 1.3M, long 931.00m, two root non-symmetric "Bu" type support tube, diameter 0.8M, single root long 8.3M. Competent to establish 12 town Pier, 107 buttress, telescopic section 11. Support Pier spacing 8M, side-sliding bearing. Town pier for the closed-end structure of gravity, base surface into bedrock, pipe excavation slope 1:0.75 with M5 grouted rubble slope protection, 0.3M, bottom side sewer, 0.25m wide, deep 0.3m,M5 grouted rubble masonry, set maintenance step ladder on the left side, 1.0M wide. Yongxinghe-? hydropower station penstock pipes arranged along the ridge line on the plane, and nearly vertical slope contour lines, Guan Po changes with the original ground line, with shallow backfill-pipe, single-pipe water supply, the competent 1.4m, long 1063.506m, two asymmetric "y" pipe, diameter 0.8M, single 10m. Competent to establish 12 town Pier, 8 expansion joint. Town pier for the closed-end structure of gravity, placed on soft rock base surface, pipe concrete C20 on a pedestal. Pipe trench excavation slope 1:0.75, after the installation of steel tube, compacted gravel backfill material to the surface, and 1:100 slope drainage to gutters. Gutter width 0.5M depth 0.5m,M5 grouted rubble masonry. 9.2 main engineering content this standard pressure pipe and the metal structure installation part main including Yunnan province tengchong County yongxing River primary and secondary hydropower station in the of pressure pipe and the power station metal structure, which level power station pressure pipe total about 562t (containing annex); II level power station pressure pipe about 733 t (containing annex); level power station metal structure about 52.5 t, containing discharge Gate 2 hole, rushed sand Gate 1 hole, water mouth work door and the stopped dirt gate the 1 hole, Qian pool work door and the stopped dirt gate the 1 hole; Secondary power station metal junction at about 19.5 t, containing sand Gate 1 hole, water inlet water gate and trash the 1 hole; their auxiliary hoist equipment and electrical