【正文】 sent the urine sample to laboratory Insert 1cm more when urine appears 47 CPR Nursing Process in Emergency I. Assessment 1. Major evidence: sudden loss of consciousness and aortic pulsation 2. Other evidences: no heart tone, unmeasurable BP, sighlike breathing and no breathing soon, mydriasis, cyanosis II. Procedure: see the appendix III. Evaluation 1. Effective: tangible aortic pulsation, autonomous respiration, consciouness ing back, pupil constracting and responding to light 2. Noneffective: intangible aortic pulsation, dialated pupil, no autonomous respiration IV. Instruction 1. Action should be rapid and precise。 bespread the perforated napkin。 record the valid duration Cover the tray to the edge Take off gloves by grabing the out surface Immerse the gloves Smooth gloves with gauze Take off the sterile glove 46 Tidy up after the operation Sterile urethral catheterization package, 2 treating bowels, hemostat, forceps, 2 ureters, sterile cotton balls, cup, paraffn oil, swabs, kidneybasin, perforated napkin Take articles to bed Prepare to operate Scrub the vulva with sterile soultion Catheterize Prepare articles Interpret。 document the time and date Check。 brush in the following order witout missing: nails, fingers, palm, hand back, wrist, forearm, 3 inches above the elbow (pay attention to nail edges, places between fingers, wrinkles in the wrist and cubital fossa) 2. Rinse off the dirty sanitizer, fingers upward and elbow downward。 sterilize the skin Vent out the air Draw in drug solution Tighten the skin。 pull out the needle。 dispose the soiled matters, immerse the disposable syringe and needle Tidy up after the operation Prepare to draw drug solution In the tray: injection card, drugs, 5ml syringe and needle, antiseptic solution, cotton swab, kidneybasin Draw in drug solution Prepare articles Check the doctor’s instruction。 tighten the skin Insert the needle with a 5 oblique Finishing prepararion for the 1ml skin test solution。 hang over in the halfsterilized area with the cleaning out In the tray: injection card, 1ml or 5ml syringe, antiseptic solution, cotton swab, drugs, NS, bottle opener, % adrenalin hydrochloride, kidneybasin Prepare to dissolve drugs Dissolve the drugs Dispense Prepare articles Prepare drugs separately Remove the middle part of the aluminium cover。 ?untie the sleeves ?tuck the sleeves under the elbows Flush the hands。 examine Take articles to bed Check。 ？ sterilize the skin Take away the tourniquet and bolster。 fold up the screen。 move the chair to the bed end on the side with the quilt Pull down the quilt 15cm。 check the bed sheets Bottom sheet, quiltcover, pillowcase, two plastic sheets, two midsheets, anesthesia tray, covered bed brush Take articles to bed Make bed Bespread quilt cover Prepare articles Move away the bedside table Move chair to bed end。 shut off the regulator Insert a liitle more while blood present in the passaway Bottom sheet, quiltcover, pillowcase badding, and pillow d Prepare articles 32 Slip on pillocase Take articles to bed Bespread bottom sheet Bespread quilt cover Slip on quilt cover Move away the bedside table Move the chair to bed end。 brush the plastic sheet and lift on the patient Take off the soiled bottom sheet to the lower shelf of the nursing cart。 Roll the patient to lie on left side 29 Replce the bottom and midbed sheet Change the quilt cover Stand on the lfet and assit patient to lie on back 平臥薪嘗臥薪嘗 Fold inward the badding to a shape S Place a clean cover on the quilt Insert the badding into the clean cover Neaten the quilt into S。 二、搶救程序：心肺復蘇術（另附） 操作后整理 導尿 消毒尿道口→對側小陰唇→近側小陰唇→再消毒尿道口 右手持止血鉗夾尿管輕插 46cm 去孔巾→擦外陰 脫手套→移去治療盤及橡膠單、巾 協(xié)助穿褲→整理床單位 整理用物 → 記錄 → 送標本 見尿后再插入尿管 1cm 放前段尿→協(xié)助留無菌中段尿標本 拔出尿管→放彎盤內 25 三、效果評價 1．有效：能摸到大動脈博動，出現自主呼吸，意識逐漸恢復，瞳孔由大變小，對光反應恢復。 3．第三遍刷完后用無菌毛巾拭干手、臂、不得擦至肘上三寸。實驗課是培養(yǎng)學生護理技能的重要環(huán)節(jié)，通過實驗課學習和強化 操練，培養(yǎng)學生良好的職業(yè)素質，較強的護理實踐技能、敏銳的觀察、分析和判斷問題的能力。為后期其他護理專業(yè)課程的學習及臨床護理 5 打下堅實的基礎。洗完畢后，手臂不能下垂，應在胸前保持拱手姿勢。 2．無效：不能摸到大動脈搏動，瞳孔散大，無自主呼吸。 take off the soiled cover Shape quilt into a tube along the bed two sides。 brush the mattress。 place articles on the chair 被套、帶套床刷 Perform on the chair Stand on right side of the bed。 place articles on chair Bespread the left side to the bed end Bespread the right part of the bottom sheet。 fold inward the two sides into tubeshape。 open the window and door Immerse the anal tube in the antiseptic solution Vent air from the tube。 ？smooth the bed sheets Dispose the soiled matters Send the blood sample to the laboratory Require patient to clench the fist。 interpret。 ? brush the forearms, ? back of hands, ?palms, fingrs, and nails Flush the hands。 sterilize the bottle cover Check the 1ml syringe。 change on the size 4 needle Inject drug solution。 check the drugs。 press down。 form a 3040 bevel between the syringe and the skin Insert the needle。 hands hanger over the elbow