《常见护理技术操作并发症预防及处理.pdf》由会员分享，可在线阅读，更多相关《常见护理技术操作并发症预防及处理.pdf（24页珍藏版）》请在三一文库上搜索。
1、out city created, and care masses life, focus work, in-depth investigation, more out bouti que masterpie ce, makes we of research re sults more to into led of decision vi sion, more to in national some has effect of newspaper Shang published, for advance work, and publicity cha ngde play due of role
2、. Third, information submitted to be pragmatic. Quick nd timely. T he ancients said: for the time system; statement back for the time being, nothi ng. Therefore, the submission of information to do “four“, that is, find the problem faster, editorial writing, send and read faster approval and feedbac
3、k to implement quickly. To be true and accurate. True mainly reflect the full picture of events, one is one, two, this is the life of the information. Accuracy is primarily qualitative and quantitative questions, quantitative objective of publicQualitative logic. To be reliable and useful. We submit
4、 information to have access to decisi on -making, to guide and promote the work and solve practical problems. Mixed cum. On the negative information and emergency i nformation, rapid e scalation i n strict accordance with the procedures, firm, newspape r, newspapers, never late, fail to report, fals
5、e claim and skimming. Investee 2. supervision and insist on, around and protecti ng their interests to touch the truth, see k practical results. Adhere to people -oriented, the most important thing is to realize, safeguard and develop the fundamental interests of the overwhelming majority of the peo
6、ple. We carry out inspection, so must go deep among the masses, go dee p into the realities, always pay attention to the peoples livelihood, to grasp t he public sentiment, and earnestly safeguard the benefit, addressing the masses are most concerned about and reflecting the strongest issues, effort
7、s to solve the pr oblem of decisions implemented and not implemented. One is to stick to principles. R ight of inspection is one of the most important powers of the Office, should not only dare to use, but also with cauti on. So-called dared to use, i s to hold a number of important issues, bold sup
8、ervision over supervision, track inspection, problems are not solved do not pass, the blame does not hold did not miss, dissatisfaction of the masses did not miss, the real right of supervision authority, with the benefits. Call with cauti on, is supervisi ng departments should strengthe n the consc
9、iousness of authorized strictly according to pr ocedure, preventing the supervision and excessive to prevent adding burden to grass-roots. To this end, the supervision Department of the Party Committee of supervision must be under city and County party Committee Secretary-General (Office). Second, w
10、e should focus on. Is the Governor, those related to the globalEvent, Governor the protracted difficult, strong Governor during emergency urgent. Not having special departments in charge of the General Governor, under the normal procedure can do good things not Governor, not a uthorized by County le
11、aders, not the Governor. Third is to solve the problem. The purpose of supervision, to resolve the problem. To adhere to and further improve the eelings survey, by looking up public sentiments to find pr obl ems. Problems will increase its special supervision, set up accounts, hol d on to it. We sho
12、ul d conscientiously implement the leading contracting matters, secured, had a n answer to everything, then settles rate of 100%. Have an impact on some of the outstandi ng issues, supervision departments and information components together, play the supervisory role of the news media to promote pro
13、bl em solving. Investee 3. insist on a daily run, around the practice of truth catching efficiency, focus specification. To give full play to the party Office around connecting, coordinating internal and external features, contact, rally at all levels, to motivate every aspe ct, adhere to the truth,
14、 strengt hening standardized management to achieve coherent, efficient and effective functioning of the daily work of the Party Committee. Is processing messages should strive to streamline, standardize and quality. Streamlining is to control the number of messages, compress messages, reducing proce
15、dures, improve message handling efficiency. Specifications, is to strictly enforce the ban issued by the Communist party authorities in document han dling regulations and pr ovincial and municipal regulations, conscientiously strengthen and improve communications management to ensure that party docu
16、ments orderly. High quality, is to improve the quality of message processing, it is necessary to accurately implementing the intention of the Party Committee, clearance, good communications, poli cy pr ogram closed, ensuring that there is no error. Second meeting scheduled to ensure thorough, safe a
17、nd efficient. Any arrangements for the meetings a nd events, carefully arranged, item-by -item interface implemented, sure. o vigorously streamline meetings, activities, number of pressure reduction, scale to ensure that leadership emerged from the General Conference and entertainment services, focu
18、s on big things, matters. Third, recepti on services should lay stress on humane, personal, cultural and human. Reception and work directly with people, recepti on services directly affecting the Office of party Committee The image of the region. At the same time strengthening the construction of li
19、brary, improve the re ception conditions, more human-ori ented, personal, cultural work into the reception, a little more human needs, a little more human care more humane atmosphere, and constantly improve the service, improve the quality of service. M eanwhile, t o further pay special attention to
20、 the daily w ork of the other Office System. Confidential work responsibility system for leading cadres to implement security as a leader, to improve the confidentiality of classified personnel, especially leading ca dres, strengthening party and Government focus on vital sectors of security managem
21、ent, to advance privacy management standardization, modernization of security techniques a s a means of administration according to law and security enforcement, ensure the safety of the party and State secrets. Confidential work to meet the demands of new technology development 常见护理技术操作并发症预防及处理流程 一
22、、口腔护理技术操作并发症 （一）口腔损伤 1发生原因 （1）在口腔擦洗过程中，由于护理人员动作粗暴，裸露的止血钳尖端碰伤口腔黏膜及牙龈， 特别是肿瘤患者放疗期，口腔有感染及凝血功能差的患者，容易引起口腔黏膜及牙龈的损伤。 （2）为昏迷患者进行口腔护理时，使用开口器协助张口方法不正确或力量不当，造成患者 口腔、牙龈或口腔黏膜损伤。 （3）漱口液温度或浓度不当，造成口腔黏膜灼伤。 2临床表现 （1）口腔黏膜充血、出血、水肿、炎症反应、溃疡形成，患者主诉口腔疼痛，颌下可触及 淋巴结肿大。 3预防及处理 （1）为患者进行口腔护理时，动作要轻柔，避免止血钳的尖端直接触及患者口腔黏膜。 （2）对凝血功能机
23、制差、有出血倾向的患者，擦洗过程中特别要注意防止碰上黏膜及牙龈。 （3）对需要使用开口器协助张口的患者，应将开口器包上纱布从臼齿处放入，以防损伤患 者口腔黏膜或牙齿，牙关紧闭者不可使用暴力使其开口。 （4）根据口腔具体情况选择温度、浓度适宜的漱口液。 （5）在口腔护理过程中，要注意观察口腔黏膜情况。如发生口腔黏膜损伤，应用朵贝尔氏 液、呋喃西林液或0.1%-0.2%双氧水含漱；如有口腔溃疡疼痛时，溃疡面用西瓜霜或锡类散 吹敷，必要时可用利多卡因喷雾止痛或洗必泰漱口液直接喷于溃疡面，每日 3 4 次抗感染。 （二）吸入性肺炎 1发生原因 多发生于意识障碍的患者，口腔护理的清洁液、口腔内分泌物及呕
24、吐物误入气道，是吸入性 肺炎的主要原因。 2临床表现 （1）发热、咳嗽、咳痰、气促及胸痛等，叩诊呈浊音，听诊肺部有湿性罗音。 （2）胸部 X 片可见斑片状阴影。 （3）实验室检查有白细胞增多。 3预防及处理 （1）为患者进行口腔护理时，辅助患者采取仰卧位，切记将头偏向一侧，防止漱口液流入 呼吸道。 （2）口腔护理所用棉球要拧干水分，不可过湿；神志不清患者不可漱口，以防误吸。 （3）已出现肺炎的患者，根据病情选择的抗生素积极进行抗感染治疗，并结合相应的临床 表现采取对症处理。 （三）窒息 1发生原因 （1）医护人员为神志不清或吞咽功能障碍的患者进行口腔护理时，由于粗心大意，将棉球 遗留在口腔，导
25、致窒息。 out city created, and care masses life, focus work, in-depth investigation, more out bouti que masterpie ce, makes we of research re sults more to into led of decision vi sion, more to in national some has effect of newspaper Shang published, for advance work, and publicity cha ngde play due of
26、 role. Third, information submitted to be pragmatic. Quick and timely. T he ancients said: for the time system; statement back for the time being, nothing. Therefore, the submission of information to do “four“, that is, find the problem faster, editorial writing, send and read faster approval and fe
27、edback to implement quickly. To be true and accurate. True mainly reflect the full picture of events, one is one, two, this is the life of the information. Accuracy is primarily qualitative and quantitative questions, quantitative objective of publicQualitative logic. To be reliable and useful. We s
28、ubmit information to have access to decisi on-making, to guide and promote the work and solve practical problems. Mixed cum. On the negative information and emergency i nformation, rapid e scalation i n strict accordance with the procedures, firm, newspape r, newspapers, never late, fail to report,
29、false claim and skimming. Investee 2. supervision and insist on, around and protecti ng their interests to touch the tuth, seek practical results. Adhere to people -oriented, the most important thing is to realize, safeguard and develop the fundamental interests of the overwhelming majority of the p
30、eople. We carry out inspection, so must go deep among the masses, go dee p into the realities, always pay attention to the peoples livelihood, to grasp the public sentiment, and earnestly safeguard the benefit, addressing the masses are most concerned about and reflecting the strongest issues, effor
31、ts to solve the pr oblem of decisions implemented and not implemented. One is to stick to principles. Right of inspecti on is one of the most important powers of the Office, should not only dare to use, but also with cauti on. So-called dared to use, i s to hold a number of important issues, bold su
32、pervision over supervision, track inspection, problems are not solved do not pass, the blame does not hold did not miss, dissatisfaction of the masses did not miss, the real right of supervision authority, with the benefits. Call with cauti on, is supervising departments should strengthe n the consc
33、iousness of authorized strictly according to pr ocedure, preventing the supervision and excessive to prevent adding burden to grass-roots. To this end, the supervision Department of the Party Committee of supervision must be under city and County party Committee Secretary-General (Office). Second, w
34、e should focus on. Is the Governor, those related to the globalEvent, Governor the protracted difficult, strong Governor during emergency urgent. Not having special departments in charge of the General Governor, under the normal procedure can do good things not Governor, not a uthorized by County le
35、aders, not the Governor. Third is to solve the problem. The purpose of supervision, to resolve the problem. To adhere to and further improve the eelings survey, by looking up public sentiments to find pr obl ems. Problems will increase its special supervision, set up accounts, hol d on to it. We sho
36、ul d conscientiously implement the leading contracting matters, secured, had a n answer to everything, then settles rate of 100%. Have an impact on some of the outstandi ng issues, supervision departments and information components together, play the supervisory role of the news media to promote pro
37、bl em solving. Investee 3. insist on a daily run, around the practice of truth catching efficiency, focus specification. To give full play to the party Office around connecting, coordinating internal and external features, contact, rally at all levels, to motivate every aspe ct, adhere to the truth,
38、 strengt hening standardized management to achieve coherent, efficient and effective functioning of the daily work of the Party Committee. Is processing messages should strive to streamline, standardize and quality. Streamlining is to control the number of messages, compress messages, reducing proce
39、dures, improve message handling efficiency. Specifications, is to strictly enforce the ban issued by the Communist party authorities in document handling regulations and pr ovincial and municipal regulations, conscientiously strengthen and improve communications management to ensure that party docum
40、ents orderly. High quality, is to improve the quality of message processing, it is necessary to accurately implementing the intention of the Party Committee, clearance, good communications, poli cy pr ogram closed, ensuring that there is no error. Second meeting scheduled to ensure thorough, safe an
41、d efficient. Any arrangements for the meetings a nd events, carefully arranged, item-by -item interface implemented, sure. o vigorously streamline meetings, activities, number of pressure reduction, scale to ensure that leadership emerged from the General Conference and entertainment services, focus
42、 on big things, matters. Third, recepti on services should lay stress on humane, personal, cultural and human. Reception and work directly with people, recepti on services directly affecting the Office of party Committee The image of the region. At the same time strengthening the construction of lib
43、rary, improve the re ception conditions, more human-ori ented, personal, cultural work into the reception, a little more human needs, a little more human care more humane atmosphere, and constantly improve the service, improve the quality of service. M eanwhile, t o further pay special attention to
44、the daily w ork of the other Office System. Confidential work responsibility system for leading cadres to implement security as a leader, to improve the confidentiality of classified personnel, especially leading ca dres, strengthening party and Government focus on vital sectors of security manageme
45、nt, to advance privacy management standardization, modernization of security techniques a s a means of administration according to law and security enforcement, ensure the safety of the party and State secrets. Confidential work to meet the demands of new technology development （2）有义齿的患者，操作前末将义齿取出，操
46、作时义齿脱落，造成窒息。 （3）为兴奋、躁动，行为紊乱的患者进行口腔护理时，因患者不配合造成擦洗棉球松脱， 掉入气管，导致窒息。 2临床表现 口护过程中患者突发吸气性呼吸困难，面色发绀，端坐呼吸， 三凹症阳性， 严重者出现面色 苍白，四肢厥冷，尿便失禁，抽搐，昏迷，甚至呼吸停止。 3预防及处理 （1）严格按照口腔护理的操作规范进行操作，一次只能夹取一个棉球，防止棉球遗漏在口 腔。 （2）认真检查牙齿情况。操作前看牙齿有无松动，义齿有无松动，如有活动性义齿，应操 作前取下。 （3）对于兴奋、躁动、行为紊乱的患者尽量在其较安静的情况下进行口腔护理。 （4）患者出现窒息后应立即进行处理，迅速清除吸入
47、异物，恢复有效通气；如异物已进入 气管或支气管，患者出现严重的呼吸障碍，立即用大号穿刺针行环甲膜穿刺，以改善通气， 争取时间做气管插管或气管切开。 二、鼻饲技术操作并发症 （一）鼻、咽、食管粘膜损伤和出血 1发生原因 （1）反复插管或因患者烦躁不安自行拔除胃管损伤鼻、咽、食管粘膜。 （2）长期留置胃管对粘膜的刺激引起口、鼻粘膜糜烂及食管炎。 2临床表现 咽喉部不适、疼痛、吞咽困难，鼻腔流出血性液，部分患者出现感染症状。 3预防及处理 （1）对需要长期留置胃管者选用聚氯酯或硅胶胃管，该种胃管质地软，管径小，可减少插 管对粘膜的损伤。对需要手术的患者，可采取手术麻醉后插管，以减少对患者的刺激。 （
48、2）向患者做好解释说明，取得患者的合作。操作时动作要轻稳、快捷。 （3）长期留置胃管，应用石腊油滴鼻，防止鼻粘膜干燥糜烂。 （4）按时更换胃管，每日两次做口腔护理，保持口腔湿润、清洁。 （5）鼻粘膜损伤引起的出血量较多时，可用冰盐水冷敷鼻部或用去甲肾上腺素浸湿的纱条 填塞止血；咽部粘膜损伤可雾化吸入地塞米松、庆大霉素，每日两次，每次20 分钟，以减 轻粘膜充血水肿；食管粘膜损伤出血可给予抑酸、保护胃粘膜药物。 （二）误吸 1发生原因 （1）年老、体弱或有意识障碍的患者反应差，贲门括约肌松驰造成食物反流引起误吸。 （2）患者胃肠功能减弱，鼻饲速度过快，胃内容物潴留过多，腹压增高，引起食物反流导
49、致误吸。 （3）吞咽功能障碍导致分泌物或食物误吸。 2临床表现 鼻饲过程中，患者突然出现呛咳、气喘、呼吸困难、心动过速、咳出或经气管出鼻饲液。吸 入性肺炎患者还可出现体温升高、咳嗽等症状。 out city created, and care masses life, focus work, in-depth investigation, more out bouti que masterpie ce, makes we of research results more to into led of decision vi sion, more to in national some has effect of newspaper Shang published, for advance work, and publicity cha ngde play due of role. Third, information submitted to be pragmatic. Quick and timely. T he ancients said: for the time system; statement back for the time being, nothi ng. Therefore, the submission of informat