第一篇:臨床護(hù)士交班內(nèi)容及順序
護(hù)士晨會(huì)交班順序和內(nèi)容(內(nèi)分泌科及創(chuàng)傷骨科手外科)
一、病區(qū)動(dòng)態(tài):病人總數(shù)、出入院人數(shù)
二、詳細(xì)交班:
1、出院病人:床號(hào)、姓名
2、新入院病人:床號(hào)、姓名、性別、年齡、目前診斷,目前情況
3、危重病人:床號(hào)、姓名、目前診斷,昨天及本班病情變化及處理措施和效果、特殊治療檢查結(jié)果,生命體征,??企w征,一般情況
4、手術(shù)病人:
今天手術(shù)病人:床號(hào)、姓名、目前診斷,術(shù)中大概情況,回房時(shí)間,生命體征,??企w征,一般情況 昨天手術(shù)病人:床號(hào)、姓名、目前診斷,術(shù)中大概情況,回房時(shí)間,生命體征,??企w征,一般情況
5、一般交班的病人:有特殊的或有病情變化的病人,交待主訴及處理情況,無(wú)病情變化可帶過(guò)
6、其他病人:須報(bào)告血壓或血糖、尿量、引流量等數(shù)據(jù)的病人
第二篇:ICU規(guī)范護(hù)士交班內(nèi)容
ICU規(guī)范護(hù)士交班內(nèi)容
為督促夜1班、夜2班護(hù)士嚴(yán)密觀察病情,提高夜間護(hù)理服務(wù)質(zhì)量,我科根據(jù)本科室特點(diǎn),規(guī)范了護(hù)士晨會(huì)交班及床頭交班。
一、晨會(huì)交班:每日晨會(huì)交班 時(shí),夜2班護(hù)士按照交班程序,依次交代病區(qū)現(xiàn)有病人總數(shù)、出院人數(shù)、入院人數(shù)、病危人數(shù)、病重人數(shù)、手術(shù)人數(shù)、死亡人數(shù),同時(shí)要詳細(xì)交代新入病人的床號(hào)、姓名、診斷、病情、特殊的處置,branden評(píng)分及morse評(píng)分、24小時(shí)的總液體量、鼻飼或口服量及大小便量,以及危重患者的診斷、病情及中夜班的特殊處理等。通過(guò)這種交班方式,可督促夜班護(hù)士進(jìn)一步嚴(yán)密觀察患者的病情,確?;颊甙踩耐瑫r(shí),給醫(yī)生提供準(zhǔn)備的數(shù)據(jù)。
二、床邊交班:晨會(huì)交班后,全體護(hù)士進(jìn)行床邊交接,進(jìn)入病房的順序?yàn)椋航话嘧o(hù)士、接班護(hù)士、護(hù)士長(zhǎng)及其他護(hù)士。對(duì)神志清醒的患者,首先交班護(hù)士使用禮貌用語(yǔ)問(wèn)候患者,使病人感到情切和被尊重,然后交班護(hù)士站在病人的左側(cè),接班護(hù)士及其他護(hù)士站在病人的右側(cè),護(hù)士長(zhǎng)站在床尾,交班護(hù)士按照床號(hào)詳細(xì)交接病人的床號(hào)、姓名、診斷、生命體征、血氧飽和度、意識(shí)、瞳孔的大小及對(duì)光反射、各管道情況、使用呼吸機(jī)的患者要交代呼吸機(jī)模式、潮氣量、氧濃度、呼吸頻率等,以及中夜班患者的病情及特殊處理。接班護(hù)士對(duì)交班的重點(diǎn)及病人情況進(jìn)行檢查,如各種引流管是否通暢、患者的皮膚情況及夜間實(shí)施的治療護(hù)理措施的落實(shí)情況,護(hù)士長(zhǎng)對(duì)重點(diǎn)進(jìn)行補(bǔ)充檢查指導(dǎo),并結(jié)合病情進(jìn)行相關(guān)知識(shí)的提問(wèn),以加強(qiáng)護(hù)理人員對(duì)??浦R(shí)的學(xué)習(xí)和提高。
三、集中講評(píng):(不超過(guò)10分鐘)床邊交接后,護(hù)士長(zhǎng)根據(jù)當(dāng)天的具體情況,集中全體護(hù)士,在護(hù)理站進(jìn)行短暫的點(diǎn)評(píng),具體指出落實(shí)不到位的護(hù)理問(wèn)題及病房管理問(wèn)題,并對(duì)下一班工作提出加強(qiáng)和改進(jìn)的具體措施,通過(guò)這種點(diǎn)評(píng)方式,一方面護(hù)士長(zhǎng)能及時(shí)發(fā)現(xiàn)病人存在的護(hù)理問(wèn)題,及時(shí)采取相應(yīng)的護(hù)理措施,確保病人的護(hù)理質(zhì)量能增強(qiáng)護(hù)理人員的競(jìng)爭(zhēng)意識(shí)和服務(wù)意識(shí)。另一方面,護(hù)士交班內(nèi)容、言語(yǔ)的分量和表達(dá)方式,也是在全體護(hù)理人員面前表現(xiàn)自己的過(guò)程,是相互學(xué)習(xí)、面對(duì)面相互比較的過(guò)程。
第三篇:護(hù)士交班檢討
尊敬的護(hù)士長(zhǎng):
我很抱歉,我作為一名老護(hù)士,為自己的工作不認(rèn)真及此次夜班交班不詳細(xì),流于形式感到深深地愧疚和不安,在此,我做出深刻檢討。
通過(guò)這起事故,我感到自己責(zé)任心不強(qiáng),但同時(shí)也是長(zhǎng)期以來(lái)對(duì)自己放松要求,工作作風(fēng)渙散的必然結(jié)果。自己身為值班人員,應(yīng)該嚴(yán)以律已,對(duì)自己嚴(yán)格要求!然而自己卻不能好好的約束自己,在工作中不認(rèn)真,夜班值班時(shí)不能很好了解病人病情變化及用藥情況,交班時(shí)沒(méi)有詳細(xì)交代夜間患者病情變化及醫(yī)生醫(yī)囑執(zhí)行情況,沒(méi)有很強(qiáng)的責(zé)任心,沒(méi)有本著對(duì)病人負(fù)責(zé)的態(tài)度。
整改措施:
1、加強(qiáng)理論,業(yè)余時(shí)間多看書(shū),提高自己理論水平。護(hù)士是專門(mén)職業(yè)的從事者。擁有專門(mén)知識(shí)特殊技能,對(duì)護(hù)理知識(shí)及相關(guān)藥物使用都要掌握,實(shí)事求是,提高自己對(duì)專業(yè)知識(shí)的認(rèn)識(shí),加深理解。
2、增強(qiáng)責(zé)任感,工作中端正態(tài)度。專心致志,全力投入工作。護(hù)理工作需要專心致志的,全力的投入,才能保證護(hù)患安全。重視自律,工作時(shí)認(rèn)真負(fù)責(zé),思想集中,一絲不茍,做到忙而不亂,護(hù)理工作中一絲的馬虎大意都隱藏著巨大的風(fēng)險(xiǎn),有可能因?yàn)橐粋€(gè)疏忽而使病人失去生命,也給自己照成不可彌補(bǔ)的傷害。工作中還要注意不能憑主觀印象,遇到不明白或者不肯定的問(wèn)題應(yīng)及時(shí)請(qǐng)教、匯報(bào),防止差錯(cuò),杜絕醫(yī)療事故。
3、加強(qiáng)心理素質(zhì)的理論學(xué)習(xí)和培養(yǎng),培養(yǎng)過(guò)硬的心理素質(zhì),能運(yùn)用心理學(xué)的知識(shí)科學(xué)進(jìn)行心理自我調(diào)節(jié),從而在繁忙而瑣碎的工作中避免因注意力分散、思維定勢(shì)、粗心大意,“想當(dāng)然”辦事所導(dǎo)致的差錯(cuò)事故。
感謝護(hù)士長(zhǎng)對(duì)我的鞭策,我盡量讓自己往前趕,在工作中盡快成長(zhǎng)起來(lái),能做到獨(dú)擋一面。
第四篇:護(hù)士英文交班
Good morning everyone,I was on duty in our intensive care last night,there were 3 patients who were porfromed operations, now I will show
you the main information
No.27 于浩霜
Excision [ek'si??n] cyst of bile duct plus Roux-pen-Y
choleclocho-jejunostomy was performed,she came back at 18:00
yesterday,The patients vital ['vaitl] sights were stable and no complaint
last night,This morning BP(blood pressure)is millineters
of mercury, HR(heart rate)is bpm,RR(respiration)isbpm, There was about milliter blood from the abdominal
[?b'd?min?l] drainage tube,It was madder red and was unobstracted,There was about urinal ['ju?rin?l] from the urinary canal
[k?'n?l],It was yellow,Covering on the incision was dry and renous
transfusion [tr?ns'fju:??n] was easy and smorthShe felt nansea and
vomiting at 23:00 and got better after giving maxdon 10 mg im,she felt
nausea and vomiting again at 2:00 and got better after giving a gastric
take insertiyThere was about liquid from the
gestrotestinal drainage tube It was yellow.肌注:intramuscular [,intr?'m?skjul?]
14:45:a quarter to 15/fourteen forty-five/forty-five past fourteen/3 quarters
past fourteen
22:30 :twenty-two thirteen/half past twenty-two
18:00: eighteen o‘clock/eighteen sharp<整點(diǎn)>/six in the evening
甲狀腺癌:htyroid carcinoma['θair?id] [,kɑ:si'n?um?]
甲狀腺腺瘤:htyroid adenoma[,?d?'n?um?]
乳腺癌:breast cancer[brest]
甲狀腺大部切除術(shù):subtotal thyroidectomy[,θair?i'dekt?mi]
甲狀腺癌根治術(shù):radical resection of thyroid cancer['r?dik?l]
[ri'sek??n]
改良術(shù)乳腺癌根治術(shù):modified radical mastectomy for breast cancer
[m?s'tekt?mi]
乳腺癌根治術(shù):radical mastectomy for breast cancer
乳腺癌擴(kuò)大根治術(shù):extensive radical mastectomy for breast cancer
[iks'tensiv]
肝囊腫:cyst of liver[sist]
肝移植:transplantation of liver['tr?nsplɑ:n'tei??n]
肝腫瘤:tumor of liver['tju:m?]
肝內(nèi)膽管結(jié)石:intrahepatic bile duct stone[hi'p?tik] [bail] [d?kt] 肝性腦?。篽epatic encephalopathy[en,sef?'l?p?θi]
肝葉切除術(shù):hepatolobectomy
肝膽管膽總管空腸
hepatocholedocho-jejunostomy
膽總管空腸Y型吻合術(shù):Roux-en-Y choledocho-jejunostomy 腹腔鏡探查:laparoscopic approach[?'pr?ut?]
闌尾切除術(shù):appendectomy[,?p?n'dekt?mi] Y型吻合術(shù):Roux-en-Y
肝部分切除術(shù):partialhepatectomy['pɑ:??l] [,hep?'tekt?mi] 胃腫瘤:gastric tumor['g?strik] ['tju:m?]
胰十二指腸切除術(shù):pancreaticoduodenectomy
腹瀉: performanceddiarrhoea[,dai?'ri?]
腹痛:feltbellyache['beli,eik]
經(jīng)歷手術(shù):underwent the resection of retroperitoneal tumors
硝酸甘油泵入:pumpping nitroglycerin
糖尿病:the serum glucose was 6.2 mmol/L,the patient was conscious
['k?n??s] and had no complain [k?m'plein]
血糖:serum glucose ['si?r?m] ['glu:k?us]/blood sugar
腹腔引流管:the celiac ['si:li,?k] drainage tube was unobstructed
['?n?b'str?ktid] and about 80mls blood was drained [drein] out
硝酸甘油舌下含化:0.5mg myocon was given by sublingual [s?b'li?gw?l] administrution
心痛定:adalat was given by sublingual administration
地塞米松5mg靜推:5mls corson was give intravenously[,intr?'vi:n?sli] 惡心、嘔吐:nausea ['n?:?i?]vomiting ['v?mit]
尿量和腹部切口敷料:urinary ['ju?rin?ri] volume was normal and covering ['k?v?ri?] on the operative incision was dry
杜冷?。簊auteralgyl安痛定:Alidine
山莨菪堿:anisodamine強(qiáng)痛定:bucinperazine
胃復(fù)安:maxolon發(fā)燒:fever
第五篇:醫(yī)務(wù)科參加臨床科室早交班工作內(nèi)容
醫(yī)務(wù)科參加臨床科室早交班工作內(nèi)容
醫(yī)務(wù)處領(lǐng)導(dǎo)用三個(gè)月時(shí)間參加全院臨床各科室早交班工作。主要對(duì)十五項(xiàng)核心制度執(zhí)行情況、電子病歷的使用和管理、手術(shù)部位標(biāo)識(shí)情況、抗菌藥物的合理使用、臨床路徑工作開(kāi)展情況、單病種工作實(shí)施情況進(jìn)行調(diào)研,了解科室對(duì)等級(jí)醫(yī)院評(píng)審標(biāo)準(zhǔn)的學(xué)習(xí)、準(zhǔn)備和開(kāi)展工作情況,并聽(tīng)取了科室發(fā)展中存在的問(wèn)題以及科室對(duì)醫(yī)務(wù)處工作的意見(jiàn)和建議。
通過(guò)此項(xiàng)工作增強(qiáng)臨床科室主任的管理意識(shí),推動(dòng)了醫(yī)療質(zhì)量的提高,也促進(jìn)了醫(yī)務(wù)處工作的不斷改進(jìn)。