【正文】 在長期醫(yī)囑單上，注明日期和時間。各種通知單如X線檢查單、心電圖申請單、會診單等應(yīng)按分工及時送病人到有關(guān)(3)臨時備用醫(yī)囑：日間的備用醫(yī)囑僅日間有效，如未用則于下午7時失效。注銷時由護士用紅筆寫“未用”(1)(2)藥物要注明具體劑量(如克、毫克、濃度、毫升)不得籠統(tǒng)寫成片、支、丸等，藥物使用(3)醫(yī)囑必須經(jīng)醫(yī)生簽名后方為有效，在一般情況下不執(zhí)行口頭醫(yī)囑。(4)如未執(zhí)行的醫(yī)囑須取消時或?qū)戝e須更改時，應(yīng)以紅筆注寫“作廢”二字，并寫明時間，由寫作廢者本人用紅筆簽名，不可涂改和撕毀。(3)凡記錄出入水量者，由總結(jié)24小時出入量(前一日8Am—當(dāng)日8Am)，在截止時間下面用紅(1)護理記錄單為重要的病情資料，填寫時應(yīng)當(dāng)做到格式正確、字跡工整、簡明扼要、詞語通順、使用醫(yī)學(xué)術(shù)語、能夠真實反映病情、準(zhǔn)確記錄出入水量。夜班入院的病人床號、姓(6)所報告病人為病危、新入院、轉(zhuǎn)入、當(dāng)日手術(shù)、次日手術(shù)或分娩者，在診斷下面一格內(nèi)用紅鋼筆分別注明*(7)2出院、轉(zhuǎn)科、轉(zhuǎn)院、死亡病人、新入院、轉(zhuǎn)入病人、重危、準(zhǔn)備手術(shù)或施行手術(shù)(1)出院、轉(zhuǎn)出(轉(zhuǎn)科、轉(zhuǎn)院)、死亡病人：要寫明床號、姓名、診斷及離開科室時間。死亡病人要記錄搶救經(jīng)過及心跳、呼吸停止的時間。(3)重危病人：報告生命體征、主訴、病情變化，特殊(4)手術(shù)病人：報告生命體征、麻醉方式，施行何種手術(shù)，返回病房時間，手術(shù)及麻醉的扼要情況，麻醉蘇醒時間，回病房后病情，如血壓有無變化，傷口敷料(5)(6)產(chǎn)婦：報告胎次、產(chǎn)程、分娩方式、時間及會陰切口和惡露情況。第五篇：臨床常用護理技術(shù)操作規(guī)程及評分標(biāo)準(zhǔn)2015目錄第一部分 常用護理技術(shù)操作規(guī)程................................1鼻飼并發(fā)癥一誤吸處置（護理）流程...............................................................................1 肌肉注射并發(fā)癥斷針處置流程..........................................................................................2 簡易人工呼吸氣器使用技術(shù)操作規(guī)程...............................................................................4 口腔護理并發(fā)癥—窒息護理處置流程................................................................................8 密閉式靜脈輸液技術(shù)操作規(guī)程...........................................................................................9 輸液并發(fā)癥—急性肺水腫處置（護理）流程..................................................................12 膀胱沖洗操作規(guī)程.............................................................................................................13 鼻飼法操作規(guī)程.................................................................................................................15 穿脫隔離衣法操作規(guī)程.....................................................................................................19 動脈血標(biāo)本采集操作規(guī)程.................................................................................................26 會陰沖洗技術(shù)操作規(guī)程.....................................................................................................29 靜脈留置針輸液技術(shù)操作規(guī)程.........................................................................................34 靜脈注射技術(shù)操作規(guī)程.....................................................................................................38 口鼻吸痰技術(shù)操作規(guī)程.....................................................................................................42 口服給藥技術(shù)操作規(guī)程.....................................................................................................44 口腔護理技術(shù)操作規(guī)程.....................................................................................................47 靜脈輸液泵/輸注泵使用技術(shù)操作規(guī)程............................................................................49 女患者導(dǎo)尿技術(shù)操作規(guī)程.................................................................................................52 皮內(nèi)注射技術(shù)操作規(guī)程.....................................................................................................55 皮下注射技術(shù)操作規(guī)程.....................................................................................................57 生命體征監(jiān)測技術(shù)操作規(guī)程.............................................................................................60 臥床患者更換床單技術(shù)操作規(guī)程.....................................................................................62 無菌技術(shù)操作規(guī)程.............................................................................................................65 心電監(jiān)測技術(shù)操作規(guī)程.....................................................................................................67 徒手心肺復(fù)蘇技術(shù)操作規(guī)程.............................................................................................69 心臟電除顫技術(shù)操作規(guī)程.................................................................................................72 血糖監(jiān)測技術(shù)操作規(guī)程.....................................................................................................74 壓瘡的預(yù)防技術(shù)操作規(guī)程.................................................................................................76氧氣吸入技術(shù)操作規(guī)程.....................................................................................................79 真空負(fù)壓靜脈采血技術(shù)操作規(guī)程.....................................................................................82 軸線翻身技術(shù)操作規(guī)程.....................................................................................................84 自動洗胃機洗胃技術(shù)操作流程.........................................................................................86第二部分常用護理技術(shù)操作評分標(biāo)準(zhǔn).......................91鼻飼并發(fā)癥誤吸處置（護理）評分標(biāo)準(zhǔn)........................................................................91 肌肉注射并發(fā)癥斷針處置（護理）評分標(biāo)準(zhǔn)................................................................92 簡易人工呼吸器使用技術(shù)操作評分標(biāo)準(zhǔn).........................................................................93 口腔護理并發(fā)癥—窒息護理技術(shù)操作評分標(biāo)準(zhǔn).............................................................94 密閉式靜脈輸液技術(shù)評分標(biāo)準(zhǔn).........................................................................................95 輸液并發(fā)癥急性肺水腫處置流程（護理）評分標(biāo)準(zhǔn)....................................................96 膀胱沖洗技術(shù)操作評分標(biāo)準(zhǔn).............................................................................................97 鼻飼技術(shù)操作評分標(biāo)準(zhǔn).....................................................................................................98 穿脫隔離衣操作評分標(biāo)準(zhǔn).................................................................................................99 床上洗頭技術(shù)操作評分標(biāo)準(zhǔn)...........................................................................................100 大量不保留灌腸技術(shù)操作評分標(biāo)準(zhǔn)...............................................................................101 動脈血標(biāo)本采集技術(shù)操作評分標(biāo)準(zhǔn)...............................................................................102 會陰沖洗技術(shù)技術(shù)操作評分標(biāo)準(zhǔn)...................................................................................103 肌內(nèi)注射技術(shù)操作評分標(biāo)準(zhǔn)...........................................................................................105 靜脈留置針輸液技術(shù)操作評分標(biāo)準(zhǔn)...............................................................................106 靜脈注射技術(shù)操作評分標(biāo)準(zhǔn)...........................................................................................107 口鼻吸痰技術(shù)操作評分標(biāo)準(zhǔn)...........................................................................................108 口服給