常见输液并发症及处理

常见输液并发症及处理 (3)持针座将导管全部送入血管 未推送软管扣3分 (4)嘱患者松拳，松开止血带抽出金属针芯， 打开调节器观察输液是否通畅。 8、无菌敷贴作密闭式无张力固定，并注明穿敷贴使用不正确扣3分，未注明5 刺日期、时间、穿刺者姓名(工号);用胶贴时间扣3分 做交叉将钢针柄妥善固定。 滴速不符合要求扣3分未核对扣 9、根据患者病情调节滴速，必要时使用输液2分 3 巡视卡(请您不要自己调速，在输液过程中 若需要帮助请按床头铃，我们也会经常来看 看您的)，在次核对(××，药液已输上，手这 样放舒服吗,) 10、协助患者取舒适卧位将呼叫器放于病人卧位不适扣1分，未宣教呼叫器2 易取处并宣教呼叫器的使用(穿刺未成功:的使用扣1分 真对不起，给您增加痛苦了，再配合一次好 吗,要不我另请一位护士老师来帮忙，好 吗,) 11、离开时交代注意事项:不要将穿刺部位3 浸在水中，尽量不要压迫穿刺肢体(××，谢未交代注意事项扣3分 谢您的合作，为了保证留置针的正常使用， 请您注意:洗手时不要将留置针浸在水中， 睡觉时尽量不要往穿刺测压，为防止针头脱 出药液外渗，活动时动作要慢一些 ) 12、清理用物，洗手，根据需要 13、使用时观察留置针通畅情况及患者主诉 5 14、输液完毕(谢谢您的提醒，对不起～请3 您稍等一下，我马上就来) 15、缓慢脉冲式推注2-5ml 封管液作正压封未观察扣2分 3 管或根据要求拔出留置针。 封管方法不正确或撕除粘膜方法 16、清理用物，洗手，根据需要记录 不正确扣2分 3 未洗手扣2分 效1、严格无菌技术操作和查对制度 违反无菌操作原则查对不严格扣5 果2、操作熟练、，穿刺一次成功 5分 5 评3、关爱病人，沟通有效 穿刺一次不成功扣5分 5 价4、静脉留置针期间病人掌握注意要点，无静关爱病人不够扣5分 5 脉炎发生 交代病人不够扣2分，有静脉炎20 分 发生扣3分 method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of 从导入鞘内取出穿刺针 13 1、让助手松开止血带，病人松拳 2、左手中指按压导入鞘前端静脉，减少血液溢出 3、按下针尖保护按钮，确认穿刺针回缩至保护套内 4、将针尖保护套放入锐器收集盒 置入导管 14 1、用镊子夹住导管尖端，将导管匀速送入静脉 2、松开左手中指，固定导入鞘针翼 3、边送导管边撕开导管护套 4、置入导管至肩部位置时，嘱病人下颌靠近术侧肩膀，导管顺利通过后，头恢复原 位 退出导入鞘: 15 1、置入导管10-15cm之后，即可退出导入鞘 2、按压导入鞘上端静脉，退出导入鞘，使其远离穿刺部位 劈开并移去导入鞘 16 1、劈开导入鞘并从导管上剥下 2、在移去导入鞘时注意保持导管的位置 继续置入导管:均匀缓慢地将剩余导管置入静脉至0刻度 17 抽回血，再次确认穿刺成功 18 1、如果回抽困难，将导管退出少许重新操作 2、抽回血不要超过圆盘 移去导引钢丝: 19 1、一手固定导管圆盘，一手撤导丝:移去导丝时，要轻柔缓慢 2、将导丝放入锐器收集盒内 正压封管，导管末端连接肝素帽或无针正压接头 20 清理穿刺点: 21 1、移去孔巾 2、用酒精棉签清洁穿刺点周围皮肤，切记不要刺激穿刺点 3、待干后可应用皮肤保护剂 固定导管，覆盖无菌敷料: 22 1、将体外导管放置呈“S”状弯曲。用胶布固定圆盘 2、在穿刺点上方放置4×4cm小纱布吸收渗血，并注意不要盖住穿刺点 3、覆盖10×12 cm无菌透明贴膜在导管及穿刺部位，贴膜下缘不要超过圆盘 4、用第二条胶布从圆盘下交叉固定导管，第三条胶布再固定圆盘 5、整理用物 x线检查: 23 x线拍片确定导管尖端位置并记录检查结果 PICC穿刺后的记录: 24 1、记录置入导管的长度、胸片位置 2、导管的型号、规格、批号 3、所穿刺的静脉名称、臂围 4、穿刺过程描述--是否顺利、病人任何不适的主诉等 method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of 连接输液，观察流速并记录 25 向病人或家属解释日常护理要点并确认 26 2.后段修剪式PICC: 项分操作方法 扣分 目 值 1、护士准备:着装整齐，洗手、戴圆帽、口罩 一项未做到扣1分 3 2、病人准备:了解病情及出凝血时间，评估病人局部静脉评估少一项扣分 5 与皮肤情况，解释操作方法，取得配合，签署置管同意书 3、物品准备:卷尺一把，止血带、无菌手套2副、PICC 导管一个、穿刺包一个(2个换药碗，2把止血钳、大棉球用物缺一项扣0.5分 10 操6个纱布若干，无菌治疗巾2块、洞巾一块、剪刀1把) 作碘伏、75%酒精、NS100ml注射器1副，透明贴膜 前10cm×12xcm1张，无菌输液贴1包，小软枕1个，无菌 准手术衣、无菌大单各1件，污物桶1个 备4、环境准备:房间紫外线消毒，使用隔帘，注意保护病人 20隐私;冬天注意保暖，环境清洁无尘 环境准备未做扣2分 2 分 method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of 1、备齐用物，推车携至病人床边，再次核对病人 未核对扣1分 1 2、解释操作目的、方法，要求病人掌握配合要领，放松情未解释扣0.5分，病人没有掌握2 绪，将软枕垫于穿刺手臂下 配合要领扣1分 3、选择合适的静脉(一般选择贵要静脉或头静脉，肘正中未按要求每处扣0.5分 3 静脉)，在预穿刺血管部位以上8cm扎止血带 4、评估静脉情况确定最佳穿刺静脉 未按要求扣1分 1 5、松开止血带 未及时松止血带扣1分 1 6、测量定位: 8 (1)病人平卧，手臂外展与躯干成90度 上臂围不符合要求扣3分未测导 (2)确定置入导管长度:从预穿刺点沿静脉走向量至右胸管置入长度及测不准扣4分未记 锁关节再向下至第二、三肋间隙 录扣1分 (3)测臂围:肘横纹上10cm处测臂围 打开无菌包、戴手套不正确各扣 7、记录测量的数值 0.5分 1 8、建立无菌区:(1)打开无菌包，戴手套 消毒不达要求扣3分 8 (2)以预穿刺点为中心消毒，做全臂消毒，75%酒精三遍，不合格每处扣0.5分 碘伏三遍 (3)将第一块无菌巾点与病人手臂下，用无菌大单覆盖患物品污染、利多卡因抽吸不正确 者 各扣0.5分 操(4)摘去手套，快速手消毒剂消毒手，穿无菌手术衣，密 作闭法戴手套并冲洗手套上的滑石粉，擦干手套，铺洞巾及 方治疗巾，保证无菌区足够大 导管未预冲及检查，未充分湿润 法9、取20ml注射器抽吸生理盐水，以1ml注射器抽吸0.5ml导管各扣2分 1 与利多卡因局麻用 程10、先预沖导管，以便检查导管是否完整有无破损，再湿3 序润导管表面，而后预沖连接管、肝素帽、穿刺针 损伤血管扣1分 6011、以利多卡因局部麻醉穿刺点 穿刺失败扣5分 分 12、让助手在上臂系上止血带，使静脉充盈 未按压导管鞘尖端处静脉扣1分 13、取出导管穿刺针 未松止血带扣1分 14、一手固定皮肤，另一手以15-30度角进行静脉穿刺，6 见回血，减少穿刺角度，推进1-2mm保持钢针针芯位置， 单独向前推进外插管鞘，避免由于推进钢针造成血管壁损暴力送管扣3分 伤，松止血带，一手拇指固定插管鞘，食指或中指按压插置入长度不准确扣1分 管鞘末端静脉，防治出血，另一手撤出针芯 15、固定好插管鞘，将PICC导管自插管鞘内缓慢、匀速退出导管动作不轻柔扣1分 4 地推进，至腋静脉时，病人向静脉穿刺侧转头以防止导管未按要求一处扣1分 误入颈静脉，导管送入达测量长度时，退出导管鞘 未做到各扣1分 16、将导管与导丝的金属柄分离，轻压穿刺点上以保持导3 管的位置，缓慢将导丝撤出 未清理皮肤扣1分 17、保留体外5cm导管以无菌剪刀垂直剪断导管，注意不固定方法不正确扣1分 要剪出斜面或毛楂(注:导管最后1 cm一定要剪掉)，接好5 各连接管，用20ml注射器抽吸回血，见回血后立即用生理 盐水20ml脉冲式冲管，正压封管，安装肝素帽 18、擦净穿刺点周围血迹，将体外导管盘绕一流畅的弯曲， 以无菌纱布覆盖穿刺点，再用无菌透明贴固定外导管，以2 method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of 输液贴交叉固定连接管和肝素帽 4 19、根据病情需要使用弹力绷带包扎 20、妥善安置病人，整理用物，向病人交代有关注意事项 为交代注意事项扣1分 2 21、X线检查确定导管尖端位置 未检查扣1分 3 22、洗手、记录 未做到各扣1分 2 结1、动作轻巧，操作熟练穿刺准确导管末端位置正确，无菌操作不熟练，流程不正确扣10分 10 果观念强 未关心爱护病人扣2.5分，未指 及2、尊重关心爱护病人及予导管相关知识指导 导扣2.5分 5 评3、用物、污物处理恰当 处理不当扣1分 5 价 20 分 (三)PICC换药流程及质量评价标准 项操作方法 分扣分标准 目 值 操1、护士准备:着装整齐，洗手，剪指甲，戴圆帽、口罩、未洗手扣3分 5 作语言轻柔 未戴口罩扣2分 前2、病人准备:评估患者病情、配合程度、导管长度、穿刺一项未做到扣1分 4 准点局部情况 备3、物品准备:卷尺一个，快速手消毒液，导管换药包(内用物缺一项扣0.5分，主要用物少一8 method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of 含:治疗巾、弯盘、治疗碗各一个，血管钳2把，纱布2项扣1分 20 分 块，大棉球6只)冲管液，碘伏，75%酒精，10ml注射器， 输液接头，透明敷料(10cm×12cm)，无菌胶带，污物桶 4、环境准备:安静，温暖，光线适宜，清洁无尘 环境未准备扣3分 3 操1、携用物至患者床头，核对患者，解释操作目的及配合要未核对及解释扣1分 3 作求 方2、协助患者取舒适体位，暴露穿刺部位，检查穿刺点有无部位暴露不佳或未检查穿刺点各扣4 法触痛及分泌物，查阅上次维护记录 1分 与3、测量上臂围，并记录 1 程4、去除原有贴膜(从下向上，避免牵动导管) 去除贴膜方向及手法不对扣1分 2 序5、再次观察穿刺点局部有无红、肿、渗血、渗液等，询问未观察局部情况扣1分，未询问病2 病人有无疼痛感 人主诉扣1分 60 分 6、观察导管外露部位的长度并记录 未观察导管长度及未记录各扣1分 1 7、快速手消毒液消毒手15秒，打开导管换药包，将注射为消毒手扣2分，未检查导管换药8 器、无菌贴膜，输液接头以无菌技术打至换药包内，请到包的有效期扣2分，未检查包内消 碘伏及酒精 毒指示卡扣3分 8、戴无菌手套，抽取冲管液并预冲输液接头，铺无菌治疗未预冲输液接头扣2分 5 巾予患者置管手臂下，左手用无菌纱布提起导管接头，右 手持血管钳消毒 9、以穿刺点为中心，用75%酒精棉球环形消毒穿刺点1cm方向、消毒范围不正确各扣3分 8 以外皮肤，范围为10cm*10cm连续三次方向为:顺时针- 逆时针-顺时针，待干 10、碘伏棉球按压穿刺点3秒后再以穿刺点为中心环形消碘伏未按压穿刺点扣2分 8 毒皮肤三次(方法同上)，将体外导管流畅放置 消毒时间不够扣2分 11、取下原有输液接头，用75%酒精纱布擦拭消毒连接器5 15秒(横断面及螺口外面均要消毒) 生理盐水少于10ml扣2分，手法不 12、连接备用输液接头，以10ml冲管液脉冲式冲洗导管并对扣3分 5 正压封管 未交叉固定扣2分 13、固定:胶带1固定连接器，覆盖透明贴膜(无张力法)，5 胶带2蝶形固定连接器，胶带3垫予导管下，两侧向上黏 在覆盖贴膜贴膜上，胶带4固定于胶带2之上 14、贴膜上注明更换日期、时间、及操作者姓名 未做到各扣0.5分 1 15、脱手套、洗手，记录填写维护电子表格 未洗手扣2分 2 结1、动作轻柔，操作熟练 操作不熟练扣5分 果2、严格无菌操作，皮肤清洁、消毒彻底 无菌观念不够、皮肤消毒不严扣5 及3、关爱病人，敷贴外贴及导管固定美观，不影响活动 分 评4、用物、污物处理恰当 未关心爱护病人扣3分，固定及贴 价敷粘效果不佳扣5分 20 分 处理不当一处扣2分 method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of (四)CVR维护流程及质量评价标准 项分操作方法 扣分标准 目 值 操1、护士准备:着装整齐、洗手、戴口罩 未洗手扣3分 5 作2、病人准备:患者合作程度、导管长度、穿刺点局部情未戴口罩扣2分 4 前况、贴膜情况 一项未做到扣1分 准3、物品准备:快速手消毒液，卷尺、导管换药包、治疗8 备碗2个，镊子2把、75%酒精棉球3个，纱布两块，碘伏用物缺一项扣0.5分，主要用物少 棉球3个，治疗巾1块，无菌手套、透明贴膜10cm*12cm1一项扣1分 20 分 张，无菌胶带4根、20ml 注射器、0.9%NS和3-5ml 肝 素稀释液(10-100u/ml)肝素帽1个，弯盘1个，清洁治 疗垫 环境未准备扣3分 4、环境准备:安静，温暖，光线适宜，清洁无尘 3 操1、携用物至患者床头， 未核对及解释扣1分 作2、核对患者，解释操作目的及配合要求 8 方3、、协助患者取舒适体位，暴露穿刺部位 部位暴露不佳或未检查穿刺点各5 法4、去除原有贴膜(从下向上，避免牵动导管) 扣1分 5 与5、再次观察穿刺点局部有无红、肿、渗血、渗液等，询5 程问病人有无疼痛感 去除贴膜方向及手法不对扣1分 序6、观察导管外露部位的长度并记录 未观察局部情况扣1分，未询问病2 7、消毒手戴手套 人主诉扣1分 602 分 8、以穿刺点为中心，用75%酒精棉球环形消毒穿刺点1cm 未观察导管长度及未记录各扣1分 10 以外皮肤，范围为15cm*15cm连续三次，待干2分钟 为消毒手扣2分，方向错误扣2分。 9、碘伏棉球按压穿刺点3秒后再以穿刺点为中心环形消消毒范围不够扣2分，漏消毒一处 毒皮肤三次，消毒范围为15cm*15cm以上，待干 扣1分，未待干扣2分 10、取下原有输液接头，用75%酒精纱布擦拭消毒连接器 污染接口扣2分 2 11、连接备用肝素帽， 8 12、用20ml生理盐水脉冲式冲洗导管 生理盐水少于20ml扣2分，手法 13、肝素稀释液脉冲式封管 不对扣3分 3 14、覆盖透明贴膜(无张力法) 贴膜方向不正确扣2分 2 15、贴膜上注明更换日期、时间、导管体内长度及操作者一项未做到扣1分 姓名 未整理床单位扣1分 3 16、整理用物及床单位 未记录扣2分 2 17、脱手套、洗手、记录 结1、动作轻柔，操作熟练 操作不熟练扣5分 5 果2、严格无菌操作，皮肤清洁、消毒彻底 无菌观念不够、皮肤消毒不严扣55 及3、关爱病人，敷贴外贴及导管固定美观，不影响活动 分 5 评4、用物、污物处理恰当 未关心爱护病人扣3分，固定及贴5 价敷粘效果不佳扣5分 20 分 处理不当一处扣2分 method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of (五)Port维护流程及质量评价标准 操1、护士准备:着装整齐、洗手、戴口罩 未洗手扣3分 5 作2、病人准备:患者合作程度、导管长度、穿刺点局部情未戴口罩扣2分 4 前况、贴膜情况 一项未做到扣1分 准3、物品准备:快速手消毒液，导管换药包(内含:治疗8 备巾、弯盘、治疗碗各一个，血管钳2把，纱布2块，大棉用物缺一项扣0.5分，主 球6只)，生理盐水及稀释肝素液，碘伏，75%酒精，10ml要用物少一项扣1分 20 分 注射器2副，输液专用无损伤针，伤口敷料，污物桶 4、环境准备:安静，温暖，光线适宜，清洁无尘 环境未准备扣3分 3 操1、携用物至患者床头，核对患者，解释操作目的及配合未核对及解释扣1分 5 作要求 方2、协助患者取平卧位，充分暴露操作视野，检查注射座部位暴露不佳或未检查5 法局部情况 穿刺点各扣1分未观察局 与3、消毒手，打开导管换药包，将输液管专用无损针、伤部情况扣1分，未观察导8 程口敷料、注射器以无菌方式打入包内，备好消毒用酒精、管长度及未记录各扣1分 序碘伏 为消毒手扣2分，未检查 4、戴无菌手套，一只注射器抽吸生理盐水并将无损伤针导管换药包的有效期扣2604 分 排气后夹闭无损伤针软管上的小夹子，一只注射器抽吸稀分，未检查包内消毒指示 释肝素液 卡扣3分 5、用无菌治疗巾覆盖患者口鼻，并嘱患者头偏向对侧 2 6、酒精棉球以注射座局为中心由内而外环形消毒皮肤，戴无菌手套不熟练扣2分 10 范围为15*15cm，方向:顺时针-逆时针-顺时针，待干 未使用治疗巾扣1分 7、碘伏棉球消毒皮肤(方法同上) 范围、方向不正确各扣310 8、左手食指和中指将输液港固定并拱起，轻柔的从输液分 5 港中心处垂直刺入穿刺隔(不要过度绷紧皮肤)，直达输 液槽基座底部 9、打开小夹子，抽吸，见回血(不能回抽至注射器)，以固定手法不正确扣3分 5 生理盐水脉冲式冲管，夹闭小夹子，换稀释肝素液，打开 小夹子，以正压封管后再次夹闭小夹子 10、用左手拇指、食指、中指固定输液港，右手垂直向上回血抽至注射器扣3分，3 拔出无损伤针后，以无菌纱布压迫穿刺局部 未正确夹闭小夹子扣2分 11、待穿刺点无渗血后，用伤口敷料覆盖穿刺点 3 12、整理用物及床单位 未覆盖穿刺点扣2分 13、脱手套、洗手、记录 未整理床单位扣1分 未记录扣2分 结1、动作轻柔，操作熟练 操作不熟练扣5分 5 果2、严格无菌操作，皮肤清洁、消毒彻底 无菌观念不够、皮肤消毒5 及3、关爱病人，敷贴外贴及导管固定美观，不影响活动 不严扣5分 5 评4、用物、污物处理恰当 未关心爱护病人扣3分，5 method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of 价固定及贴敷粘效果不佳 扣5分 20 分 处理不当一处扣2分 (七)导管冲、封管标准 冲管是指用等渗盐水将导管内残留的药物冲入血管，避免刺激局部血管，并减少药物之间的 配伍禁忌，应用于两种药物之间或封管前。封管是指保持畅通的静脉输液通路，通常使用稀 释肝素液10-100u/L，用于输液结束后。 项分操作方法 扣分标准 目 值 操1、护士准备:着装整齐、洗手、戴口罩帽子 未洗手扣3分 5 作2、评估患者:导管类型、导管是否通畅 未戴口罩扣2分 5 前3、物品准备:碘酒和酒精，10ml注射器2副，棉签，一项未做到扣1分 8 准0.9%NS*1，稀释肝素液1瓶 备4、安静，温暖，光线适宜，清洁无尘 用物缺一项扣0.5分，主要2 用物少一项扣1分 20 分 环境未准备扣3分 操1、抽吸生理盐水5-10ml，肝素水3-5ml (肝素钠的浓度为抽取液不对扣2-5分 5 作10-100u/ml ) 方2、携用物至床旁，核对床号姓名，解释目的 未核对解释扣5分 5 法3、休疗期患者先更换或摩擦消毒导管的接头 污染接头扣5分 5 与4、取下输液器，生理盐水5-10ml排气后接头皮针或正压未脉冲式封管扣5分 20 程接头(如为肝素帽头皮针可先拔至斜面处)，注射器活塞 序于大鱼际处，利用大鱼际力量脉冲式冲洗导管 5、用3-5ml肝素水接头皮针或正压接头，缓慢推注，当未正压封管扣5分 6015 分 封管液剩0.5-1ml时边推封管液边拔针头(正压接头是逆 时针方向边推边退出注射器，速度都不宜过快)。 6、妥善固定导管，交代注意事项 未妥善固定扣3分 5 7、洗手、整理用物 未交代注意事项扣3分 5 结1、动作轻柔，操作熟练 操作不熟练扣5分 6 果2、严格无菌操作，皮肤清洁、消毒彻底 无菌观念不够、皮肤消毒7 及3、关爱病人，敷贴外贴及导管固定美观，不影响活动 不严扣5分 3 评4、用物、污物处理恰当 未关心爱护病人扣3分，4 价固定及贴敷粘效果不佳扣 5分 20 分 处理不当一处扣2分 method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of (六)更换导管、敷料及输液装置标准 导管类型 导管更换或留置 敷料更换 输液装置更换 输液更换间隔 留置针 1)成人:间隔72-96小1)拔除或更换1)输液管路和1)含脂肪乳的静脉营 时更换 导管 其他辅助装置如养应在24小时内给完 2)小儿:如无并发症或2)敷料潮湿、松延长管、三通等2)单纯脂肪乳应在12 特殊需要，可不需要更动或有血迹等污的更换间隔一般小时内给完 换 染时予以更换 24小时内 3)血液制品应在4小时 3)紧急插管着，48小3)汗液较多，敷2)输注血液、血内给完 时内更换，选择另一穿料厚不易观察到液制品、脂肪乳 刺点 局部情况的需增等需单独更换输 加更换频率 液器 不需要常规更换导管， 一般间隔一年 1)纱布辅料每同上 同上 PICC 48小时更换一 次 2)透明贴膜每 7天更换一次 3)敷料潮湿敷、 松动或有血迹等 污染或检查穿刺 点时时予以更换 一个月更换 同上 同上 同上 CVC method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of 第三部分 静脉治疗常见并发症预防及处理 一、静脉炎 1、定义:静脉炎是静脉内膜的炎症，主要有机械性、化学性、细菌性以及血栓性静脉炎 2、临床表现:穿刺部位及沿静脉通路方向红、肿、热、痛，触诊静脉压痛，发硬，呈条索状，无弹性，严重着局部针眼处可挤出脓性分泌物，可伴有全身发热等症状。 3、分级标准(INS) 分级 临床表现 0级 没有症状 1级 输液部位发红伴有或不伴有疼痛 2级 输液部位疼痛伴有发红或水肿 输液部位疼痛伴有发红或水肿 3级 条索状物形成可触摸到条索状的静脉 输液部位疼痛伴有发红或水肿条索状物形成 可触摸到条索状物长度大于2.5cm，有脓液流4级 出 4、静脉炎的原因及预防措施 机械性静脉炎 化学性静脉炎 细菌性静脉炎 血栓性静脉炎 1)置管技术不高浓度、刺激性1)未严格遵守1)静脉导管插入和静脉炎原因 熟练 强的药物输入，无菌技术操作原对静脉血管化学刺 2)不适当地置超过血管的应激则 激 管部位 能力或长时间滴2)穿刺点皮肤2)静脉瓣多，血液 3)留置超时 入血管，持续刺消毒不彻底 回流慢、肢体受压、 4)导管固定松激血管导致内皮3)操作及护理手术创伤、低温、半 动未及时更换敷细胞破坏所致 方法不当 卧位等增加了血栓 料 形成的危险 5)微粒刺激 3)封管不正确 6)导管材质过 硬 1)熟练操作 尽量选择粗、直1)严格遵守无1)正确的冲封管，预防措施 2)有效固定，避血管，刺激性药菌操作和手卫生 勿按压置管侧肢体 免在关节部位穿物选择中心静脉2)使用合格产2)置管后沿静脉方 刺 输入 品，操作时最大向热敷等 3)使用合格滤无菌屏障 3)熟练操作技术， 过器 3)减少留置时提高一次穿刺成功 4)使用聚亚安间，及时更换敷率 酯(万珑)导管 料，并保持敷贴 干燥 method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of 5、处理原则 5.1、外周静脉置管部位一旦出现静脉炎应立即拔除 5.2、血栓性静脉炎必要时遵医嘱进行溶栓，如有脓性分泌物需做细菌培养 5.3、局部湿热敷或喜辽妥等软膏外涂，也可以使用康惠尔透明贴外用 5.4、抬高肢体促进血液回流，避免剧烈运动 5.5、局部消毒，严重者遵医嘱应用抗生素软膏 5.6、3级以上静脉炎必须作为不良事件上报 (二)药物外渗和渗出 1、定义 1.1、输液渗出是指输液过程中由于多种原因导致输入的非腐蚀性药液或液体渗出到正常血管通路以为的周围组织 1.2、输液外渗是指在输液过程中由于管理疏忽，刺激性药液和发泡剂或液体输入了周围组织 2、临床表现:出现输注速度缓慢，回抽输液管路无回血，轻者局部肿胀、红肿、中度或重度疼痛，常为胀痛或烧灼样疼痛、刺痛;重者皮肤呈暗紫色，局部变硬，甚至引起组织坏死 、分级标准(INS分四级) 3 分级 临床表现 0级 没有症状 皮肤发白，水肿范围最大直径小于2.5cm 1级 皮肤发凉，伴有或不伴有疼痛 皮肤发白，水肿范围最大直径2.5-15cm 2级 皮肤发凉，伴有或不伴有疼痛 皮肤发白，水肿范围最小直径大于15cm 3级 皮肤发凉，轻到中度的疼痛，可能有麻木感 皮肤发白，半透明状，皮肤紧绷，有渗出， 皮肤变色，有瘀斑、肿胀，水肿范围最小直 4级 径大于15cm，呈凹陷性水肿，循环障碍，轻 到中度的疼痛，(任何容量刺激性药液和发泡 剂或液体渗出均属于4级) 4、预防措施: 4.1、减少钢针使用:对于化疗药物建议留置针一用一拔 4.2、提高穿刺成功率 4.3、血管的选择:应避开有炎症、硬结、疤痕或皮肤病的部位进针;评估静脉血管的弹性，粗细及位置，根据血管选择合适的穿刺针;有的使用静脉，一般由远端到近端 4.4、掌握药物的性能、特点及注意事项，选择合适的输液工具和部位 4.5、做好患者的宣教，提高患者的防范意识 4.6、加强责任心、多巡视，特别是危重患者，做好床头交接班 4.7、正确拔针 4.8、对于烦躁、感觉和知觉障碍或认知水平低的患者，适当的约束 5、处理措施(见附) method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of 附:药物外渗处理流程 ?高危药物外渗应急预案 1、一旦发生药物外渗应立即停止注药 2、保留针头接空注射器尽可能回抽漏于皮下的药液，拔针头，注意按压不可用力 3、通知床位医生及护士长，并遵医嘱按外渗处理流程做对应处理 4、按并发症管理规范报不良事件并电话通知护理部和科护士长 5、做好患者及家属沟通及宣教工作，抬高患肢并严格交接班，观察局部情况 ?甘露醇、血管活性药、阳离子药物、造影剂等外渗处理流程 一，操作前准备 1、护士准备:着装整齐、洗手、戴口罩，帽子 2、评估患者:穿刺局部外渗的范围，肿胀疼痛的程度和皮肤颜色 3、物品准备:尺子一根、50%的硫酸镁或95%酒精等、纱布、一次性换药碗等 二、操作步骤 1、用尺子测量外渗范围 2、对于3cm的外渗可以更换注射部位，局部热敷或50%硫酸镁纱布湿敷 3、外渗3cm ,如在四肢，局部制动、抬高患肢，用50%硫酸镁或95%酒精持续湿敷，疼痛明显者可用康惠尔透明贴外用或50%GS+VitB12各一支纱布外敷 4、对于血管活性药物如多巴胺，有时局部肿胀虽不明显，但发红、苍白、疼痛明显，必须立即更换注射部位，局部用95%酒精或50%的硫酸镁持续湿敷，发生外渗需用对应的药物拮抗，如酚妥拉明，山莨菪碱(654-2)纱布局部热敷，必要时用拮抗剂封闭 ?化疗药物外渗处理流程 一、操作前准备 1、护士准备:着装整齐、洗手、戴口罩，帽子 2、评估患者:穿刺局部外渗的范围，肿胀疼痛的程度和皮肤颜色 3、物品准备:尺子一根，碘酒、酒精、棉签、10ml注射器，七号针头、生理盐水、利多卡因、地塞米松 二、操作步骤 1、携用物至病人床旁 2、核对床号、姓名、解释目的及配合要求 3、立即停止注射，保留针头，接注射器抽液体和回血 4、拔出针头，用棉签轻轻按压2-3分钟 5、测量外渗范围和面积，有条件拍照 6、发泡剂类药物外渗必须封闭。封闭方法，皮肤消毒后，利多卡因与生理盐水按1:1比例(视外渗范围配置不同量，最少10ml)遵医嘱加用地塞米松接七号针头，在外渗边缘至少2cm 处为注射点，要形成多点环形皮下封闭，在推药过程中边推边退，推药时匀速缓慢 7、除植物碱类药物可以热敷外，其他所有化疗药物外渗24小时内需间歇冰敷，每次15-30ml，注意防止冻伤 8、药物外敷:根据局部肿胀情况选择50%硫酸镁或中药湿敷 method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of (三)导管堵塞 1、定义:是指血管内置导管部分或完全堵塞，致使液体和药液的输注受阻或受限，最基本的2种类型是血栓性和非血栓性 2、临床表现:滴速减慢或滴注停止，无法冲管或抽回血 3、原因:造成导管堵塞的原因较为复杂，与导管被夹闭、导管尖端位置移位、导管打折、药物沉积，输入过高浓度的液体、冲封管不正确、不充分的冲洗、未定期冲管、血栓、纤维鞘阻塞、肝素帽松动致血液反流后凝固，患者的凝血机制等多种因素有关 4、预防措施: 4.1、正确评估患者的身体状况，选择合理的封管液并正确封管 4.2、合理选择穿刺静脉，并尽量减少对血管内膜的损伤 4.3、及时冲管:在输注刺激性或黏附性强的药物前后、从导管抽血后、输注胃肠外营养期间均应及时用生理盐水10ml进行脉冲式冲管。冲管时若遇到阻力，切忌加压冲洗，以免将血栓推入血管。 4.4、认真做好患者的健康宣教，防止血液反流 4.5随时观察输液速度、早期处理堵塞现象、防止完全堵塞 4.6、减少药物的联合输注，注意药物的配伍禁忌 4.7、做好治疗间歇期或出院患者的护理 5、处理措施 5.1、当怀疑导管堵塞时可尝试推注少量生理盐水，若阻力大，不可强行推注，以免将血栓推入血流造成堵塞 5.2、先检查外部因素和患者体位排除机械性导管闭塞 5.3、若无机械性堵管，再看患者输注药物有无配伍禁忌或大分子物质等，排除药物沉积堵管 5.4若考虑为凝血堵管可遵医嘱用尿激酶进行溶栓{见附} 附:溶栓操作流程 一、操作前准备: 1、、护士准备:着装整齐、洗手、戴口罩 2、物品准备:快速手消毒液，导管换药包(内含:治疗巾、弯盘、治疗碗各一个，血管钳2把，纱布2块，大棉球6只)，生理盐水100ml、肝素帽或无针接头，75%酒精，1 ml、20ml注射器若干，尿激酶 4、环境准备:安静清洁、光线适宜 二、操作方法与程序: 1、洗手，戴口罩，携用物至患者床头，核对患者，解释操作目的及配合要求 2、患者戴口罩，协助患者舒适体位，充分暴露操作视野 3、消毒手，打开导管换药包，将所需物品置入换药包内 4、戴手套，准备好5000u/ml的尿激酶液，铺治疗巾，建立无菌区 5、用无菌纱布取下原有肝素帽，用75%酒精纱布用力摩擦擦拭消毒连接器15秒，连接三通阀，三通一直臂接导管，另一直臂接配好的尿激酶溶液(5000u/ml)，侧臂接空注射器(20ml) 6、先使导管与侧臂通，回抽注射器活塞至10-20ml位置，然后迅速将三通打成两直臂通，method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of 导管内的负压会使尿激酶溶液进入导管内约0.5ml 7、将设备妥善固定，保留20-30分钟 8、20-30分钟后将侧臂空注射器转移到直臂处，回抽注射器活塞，将导管中的药液和溶解掉的血液抽回约3-5ml弃去，迅速换上抽好生理盐水的注射器，以脉冲式彻底冲洗干净导管 9、去除三通阀装置，再次用75%酒精纱布用力摩擦擦拭消毒连接器15秒，连接新输液接头，再次冲洗导管并封管 10、如果经由以上的操作，一次没有使导管通畅，可以重复几个循环，直至导管通畅 11、如导管溶栓失败，需拔除导管 三、注意事项: 1、操作采用无菌技术，遵循“标准预防”执行 2、应用负压方式，禁忌暴力冲管 3、尿激酶冰箱保存，新鲜配制 4、确定导管注入容量(根据导管说明书) (四}针刺伤标准预防及处理 1、锐器上的概念:由医疗锐器如:注射器针头、缝针、各种穿刺针、手术刀、剪刀等造成的皮肤损伤 2、职业安全防护的全球标准 免费接种乙肝疫苗、消除不必要的利器、带安全防护设置的锐器、适当的个人防护设施、艾滋病毒暴露后 3、锐器伤的预防: )医务人员在进行接触有可能接触病人各种血液、体液的诊疗和护理操作时必须戴手套，1 操作完毕，脱去手套后立即洗手，必要时进行手消毒，在采集传染病人标本时要注明隔离标记，执行安全注射，有条件时可采用真空采血系统 2)集体操作时应及时处理针头及其它锐利器械，避免集中处理的二次损伤‘碎的可能被污染的玻璃不要用手接触处理 3)禁止将针头放置在床边，使用带有预防锐器伤安全装置的锐器盒 4)有关血液与感染性材料的操作应及时戴口罩、防护眼镜，穿隔离衣，减少渗出物与渗出液 5)在进行操作时要保证充足的光线、避免损伤，使用后的污染针头及锐利器械应直接放入注明明显隔离标记的硬质安全处理盒内。污染针与其它锐器不应故意用手弯折或拔除，必须用机械方法，并禁止用双手将已使用的注射器重新套帽 6)手术时，使用消毒盘传递器械，不要直接传递，不直接用手安装锐利器械，应借助于其它工具 7)定期自我检查，发现被损的皮肤及粘膜，在进行有可能接触病人血液、体液的诊疗和护理操作时必须戴双层手套 8)如果发生锐器损伤，首先保持镇静，戴手套者迅速、敏捷的按常规脱手套，用健手立即按以下流程处理。 method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of 锐器损伤 立即局部处理用肥 皂水流动清洗污染 的皮肤，用生理盐上报医务处 立即上报水冲洗黏膜如有伤护理部、保健感染办 口应尽可能挤出血科 液(近心端向远心 端方向挤压) 查看暴露双手有 无经血传染性疾 病，必要时采血样 伤口用碘酊、乙醇 消毒必要包扎伤 口 化验(一)不作处 理 化验(+)根据疾病 要求在保健刻指导 下实施处理 定期随访 method of basic operation; including CT, and MRI various contrast, and Image-guided biopsy, ultrasound, etc. (11) teaching, scientific research and training in clinical teaching, written within three years with some level of review or book reports of not less than 1. Four, to read reference books, Journal of internal medicine (medical college planning materials) and of the medical imaging (medical college planning materials); the practical science; the Harrison Science (in English), Chinese Journal of internal medicine series. Surgical surgical specialist refers to the rules complete the medical undergraduate or graduate education Foundation, accepted and adopted surgical specialist training, surgical diagnosis, treatment, prevention and follow-up of common diseases, surgical diagnosis and treatment of rare or incurable diseases, acute and critical illness in emergency and rescue have preliminary knowledge and experience. Surgical specialist training for 3 years. A surgical specialist, training goals through training, trainees to achieve surgical specialist level, with more skilled surgical skills, can guide the teaching of