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这既是一本烧伤专科护士初入职场的指导书籍,又是一本烧伤专科护理管理者实施系统培训的教材,内容包
括专科临床护理、专科临床护理技能、应急与抢救预案、重症监护室制度、专科质量标准,以及身心并护临床护理路径和烧伤科常用各类药品的宣教篇等。专科临床护理内容涵盖烧伤基础知识和急救,从患者入院开始直至出院涉及的每一个关键环节护理,烧伤专科疾病护理全覆盖;专科临床护理技能包括基础操作和专科操作,既有通科护理操作,也有烧伤涂药、点眼、翻身床和悬浮床使用、呼吸机和血透机的应用、负压封闭引流技术等专科护理操作,共计40项;应急与抢救预案包含了39个专科常见的病情变化和突发情况的处置流程,既有专业抢救流程,也有监护室停电、护患纠纷、患者坠床等应对策略;重症监护室制度包括收治范围、转入和转出程序、探视管理、各班工作职责标准及流程、护士岗位准入标准等;专科质量标准涉及烧伤专科疾病护理质量标准和常见合并症、并发症的护理质量标准;附录中的“身心并护”临床护理路径、常用药品宣教和常用化验正常值及意义为临床护士所要了解和掌握的必需和扩充。该书由解放军总医院第四医学中心和第八医学中心的工作人员编写,将临床实践经验和研究成果相结合,编写以贴近临床,确保实用性、系统性和可操作性为原则。
时光荏苒如白驹过隙,1989年我从第四军医大学护校毕业,便与烧伤护理结缘。满怀热情和憧憬,带着在校所学有限的烧伤护理知识,初次踏入病房,面对面目全非的烧伤患者,那时的恐慌和无措,至今仍然历历在目。30余年护理生涯,我始终在临床一线患者身旁,既十分珍惜这份职业带给我的收获和成长,也坚定了要为这份挚爱的事业和更多的同行做些什么的信念。护理过上万的患者,培养带教过很多护士,在自己成长与见证他人成长的道路上,我深知一本好的实用的专科手册的确能起到事半功倍的效果,一本全面系统归纳式的指导手册能有效解决带教过程中的层层困惑。
我组织编写这本手册的目的有两点:一是满足专科发展、临床救治护理的需要。由于烧伤护理专业性强,随着医疗的快速发展,护理如何迎头赶上,是每一名烧伤护理管理者的责任担当和任务使命。当前临床存在烧伤专科护士更新快、新入职护士知识水平参差不齐、护理质量无法保障、培训任务艰巨等现状,为新护士提供实用、专业的指导手册,使其能更快地掌握烧伤护理理论、技能,更快地适应繁重的烧伤护理工作,满足临床需求。二是满足应急战备抢救的需要。近年来,火灾、爆炸、公交爆燃等突发事故频发,受伤人数多,经常会有非烧伤专科护士参与一线救护,而大面积烧伤、批量伤员救治难度大,指导这些非烧伤专科护理人员尽快熟悉专业和进入状态,使其保质保量地完成救护任务,从而提高患者的救治成功率。
目录
第一部分 专科临床护理 ·················································································1
一、烧伤基础知识 ····················································································1
二、烧伤急救护理 ····················································································4
三、烧伤入院护理 ····················································································6
四、烧伤基础护理 ····················································································9
五、烧伤创面护理 ··················································································13
六、围手术期护理 ··················································································22
七、特殊部位烧伤护理 ············································································31
八、特殊原因烧伤护理 ············································································34
九、特殊年龄烧伤护理 ············································································38
十、吸入性损伤护理 ···············································································45
十一、烧冲复合伤护理 ············································································48
十二、大面积烧伤护理 ············································································49
十三、批量烧伤护理 ···············································································57
十四、烧伤转运护理 ···············································································59
十五、烧伤康复护理 ···············································································61
十六、烧伤出院护理 ···············································································68
第二部分 专科临床护理技能(基础篇) ··························································70
一、静脉输液 ························································································70
二、皮内注射 ························································································73
三、肌内注射 ························································································74
四、皮下注射 ························································································77
五、导尿术(男性、女性患者) ································································78
六、心肺复苏(单人、双人) ···································································81
七、中心管道吸氧法 ···············································································82
八、中心管道吸痰法 ···············································································83
九、经口腔冲洗式口护吸痰法 ···································································85
十、膀胱冲洗 ························································································87
十一、卧床患者更换床单法 ······································································89
十二、静脉采血法(注射器、真空采血针) ·················································91
十三、动脉采血法(注射器、血气针) ·······················································92
十四、灌肠法 ························································································94
十五、留置胃管法 ··················································································98
十六、鼻饲法 ························································································99
十七、心电监护仪的应用 ········································································101
十八、中心静脉压测定 ···········································································102
十九、微量泵的应用 ··············································································103
二十、输液泵的应用 ··············································································105
第三部分 专科临床护理技能(专科篇) ·························································107
一、创面涂药法 ····················································································107
二、眼部滴药法 ··················································································108
三、鼻部滴药法 ····················································································110
四、耳部滴药法 ····················································································111
五、小儿口服给药法 ··············································································112
六、翻身床双人操作法 ···········································································114
七、悬浮床 ··························································································117
八、营养泵 ··························································································118
九、红光治疗仪 ····················································································119
十、半导体激光治疗仪 ···········································································121
十一、远红外线烤灯 ··············································································122
十二、振动排痰仪 ·················································································123
十三、亚低温治疗仪(降温毯) ·······························································125
十四、负压封闭引流技术 ········································································126
十五、PDA ··························································································127
十六、呼吸机 ·······················································································128
十七、GEM Premier 3000血气分析仪 ·························································129
十八、费森尤斯血透机 ···········································································131
十九、动脉血压监测 ··············································································133
二十、PICC置管 ···················································································134
第四部分 应急抢救预案及处置流程 ·······························································137
一、呼吸机使用过程中发生故障应急预案及处置流程 ····································137
二、呼吸机脱机后非计划拔管应急预案及处置流程 ·······································138
三、气管导管意外脱管抢救预案及处置流程 ················································139
四、气管套管堵塞抢救预案及处置流程 ······················································141
五、输液过程中出现肺水肿应急预案及处置流程 ··········································142
六、患者发生静脉空气栓塞应急预案及处置流程 ··········································142
七、血管活性药物外渗应急预案及处置流程 ················································143
八、患者发生躁动应急预案及处置流程 ······················································144
九、患者坠床、摔倒应急预案及处置流程 ···················································145
十、监护室突遇断电应急预案及处置流程 ···················································146
十一、护患纠纷应急处理预案及处置流程 ···················································148
十二、医疗锐器损伤应急预案及处置流程 ···················································148
十三、烧伤休克抢救预案及处置流程 ·························································149
十四、心搏呼吸骤停抢救预案及处置流程 ···················································151
十五、猝死抢救预案及处置流程 ·······························································152
十六、急性心肌梗死抢救预案及处置流程 ···················································154
十七、快速性心律失常抢救预案及处置流程 ················································155
十八、急性左心衰竭抢救预案及处置流程 ···················································157
十九、心源性休克抢救预案及处置流程 ······················································158
二十、高血压脑病及高血压危象抢救预案及处置流程 ····································159
二十一、急性呼吸窘迫综合征抢救预案及处置流程 ·······································160
二十二、咯血抢救预案及处置流程 ····························································161
二十三、重度哮喘抢救预案及处置流程 ······················································162
二十四、肺栓塞抢救预案及处置流程 ·························································164
二十五、烧伤合并急性呼吸衰竭抢救预案及处置流程 ····································165
二十六、烧伤后上消化道大出血抢救预案及处置流程 ····································166
二十七、肝性脑病抢救预案及处置流程 ······················································167
二十八、脑疝抢救预案及处置流程 ····························································168
二十九、脑出血抢救预案及处置流程 ·························································169
三十、癫痫大发作抢救预案及处置流程 ······················································171
三十一、癫痫持续状态抢救预案及处置流程 ················································172
三十二、患者出现精神症状应急预案及处置流程 ··········································174
三十三、过敏性休克抢救预案及处置流程 ···················································175
三十四、溶血反应抢救预案及处置流程 ······················································176
三十五
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