Essential Nursing Knowledge for Nurses

Essential Basic Nursing Knowledge for Nurses

In 1980 the American Academy of Nursing defined nursing as "Nursing is the diagnosis and management of human responses to existing or potential health problems." Derived from this definition, modern nursing is the science of diagnosing and treating human responses to existing or potential health problems. Emphasis is placed on "human behavioral responses" as expressed in people's behavioral responses to an event from the physical, psychological, social, cultural, and spiritual perspectives. The following is the 50 essential basic nursing knowledge for nurses that I brought for you, welcome to read.

Basic Nursing Knowledge for Nurses 1

1. Which steps are included in the nursing process?

The nursing process consists of five steps: assessment, diagnosis, planning, implementation, and evaluation.

2. What are the methods of data collection?

① Observation; ② Conversation; ③ Physical examination; ④ Consultation of relevant information.

3. How much temperature and humidity should be maintained in the ward?

(l) The temperature of the room is generally maintained at 18-22 ℃ is appropriate. Newborns and elderly patients, the room temperature is maintained at 22-24 ℃ is appropriate.

(2) The humidity of the room is generally maintained at 50% to 60%.

4. What are the common lying positions? What kind of patients are they for?

(1) decubitus supine position: for coma or general anesthesia is not awake patients; intrathecal anesthesia or spinal puncture after the patient.

(2) Mid-concave position: for patients in shock.

(3) Flexed knee supine position: for patients undergoing abdominal examination or undergoing catheterization or perineal irrigation.

(4) Side-lying position: for patients with enema, anal examination and with gastroscopy and enteroscopy; patients with intramuscular injection in the buttocks.

(5) Semi-sitting position: for patients with dyspnea caused by cardiopulmonary diseases; patients after thoracic, abdominal and pelvic surgery or with inflammation; patients after certain facial and neck surgeries; and patients with weak constitution during the recovery period.

(6) Sitting position: for patients with heart failure, pericardial effusion, and bronchial asthma attacks.

(7) prone position: for patients with lumbar and back examination or with pancreatic and cholangiographic examination; after spinal surgery or lumbar, back, buttock wounds, can not lie down flat or sideways; gastrointestinal flatulence resulting in abdominal pain.

(8) Head-down, foot-up position: for patients with drainage of pulmonary secretions; patients undergoing duodenal drainage; patients with premature rupture of membranes in pregnancy; patients with heel or tibial tubercle traction.

(9) Head-high-foot-low position: for patients with cervical spine fracture for cranial traction; patients after cranial surgery.

(10) knee-thoracic position: for patients with anal, rectal, sigmoidoscopy and treatment; patients who need to correct fetal malposition or uterine tilt. Patients; to promote postpartum uterine recovery.

(11) truncated position: for patients with perineum, anal area examination, treatment or surgery; maternal delivery.

5. What are the precautions to be taken when changing the lying position for special patients?

(1) For those who have various catheters or infusion devices, l should first place the catheter properly, turn over and then carefully check to keep the catheter clear.

(2) cervical or cranial traction, turn over, do not relax traction, and keep the head, neck and trunk in the same horizontal position turned; turn over after attention to the direction of traction, position, and traction force is correct.

(3) craniocerebral surgery, should take the healthy side of the lying position or lying position, in the turn over to pay attention to the head can not be turned violently, so as not to cause cerebral hernia, compression of the brain stem, resulting in the sudden death of the patient.

(4) plaster fixation, should pay attention to the position of the affected area and local limb blood circulation after turning over, to prevent pressure.

(5) general surgery, turn over should first check whether the dressing is dry, there is no shedding, such as secretion wet dressing, should be replaced and fixed properly before turning over, turn over to pay attention to the wound should not be under pressure.

6. What are the precautions for the use of restraints?

(1) Strictly grasp the indications for application, pay attention to maintain the patient's self-esteem.

(2) To explain to the patient and his family the purpose of the use of restraints, the main points of operation and precautions, in order to obtain understanding and cooperation.

(3) Restraints can only be used for a short period of time and should be loosened at regular intervals, and the patient should be assisted in changing positions frequently.

(4) The limb is in a functional position when it is used; the restraining belt needs to be padded under the padding, and the tightness is appropriate; closely observe the skin color of the restraining area, and if necessary, carry out local massage to promote blood circulation.

(5) Record the reason for the use of restraints, time, observation results, nursing measures and the time to release the restraint.

7. What are the components of pain assessment?

① site of pain;

② time of pain;

③ nature of the pain;

④ degree of pain;

⑤ expression of pain;

⑥ factors affecting the pain;

⑦ the impact of the pain on the patient, with or without accompanying symptoms.

8, What are the commonly used pain assessment tools?

① Numerical rating method;

② Textual descriptive rating method;

③ Visual analog rating method;

④ Facial expression measurement chart.

9. How do you apply the 0-5 textual descriptive rating method to assess pain?

Grade 0 No pain.

Grade 1 Mild pain: tolerable, able to live and sleep normally.

Grade 2 moderate pain: mildly interferes with sleep and requires pain medication.

Grade 3. Severe pain: interferes with sleep and requires narcotic pain medication.

Grade 4 Severe pain: heavier interference with sleep, accompanied by other symptoms.

Grade 5 intolerable: severe thousand disturbed sleep with other symptoms or passive position.

10. What are the stages of pressure ulcers? Briefly describe the reasons for their occurrence.

Depending on their severity and depth of invasion, they can be classified into four stages:

① ① bruising and reddish infiltration stage;

② inflammatory infiltration stage;

③ shallow ulceration stage;

④ necrotic ulceration stage.

Causes:

(1) Long-term localized pressure, friction or shear force.

(2) Localization is often subjected to moisture or excreta sting.

(3) Improper use of plaster bandages and splints.

(4) Generalized malnutrition or edema.

11. Briefly describe the compartmentalization of body mobility.

0 degree: fully independent and free to move around.

1 degree: need to use equipment or devices (e.g., crutches, wheelchair).

2 degrees: requires assistance, supervision and education from others.

3 Degrees: Needs both someone's help and equipment and devices.

4 degrees: completely unable to be independent and participate in activities.

12. Briefly describe the grading of muscular strength.

Grade 0: Complete paralysis with total loss of muscle strength.

Grade 1: Slight muscle contraction is seen but no limb movement.

Grade 2: Can move the position but cannot lift.

Grade 3: Limb can be lifted off but not against resistance.

Grade 4: Can make movements against resistance but with reduced muscle strength.

Grade 5: Normal muscle strength.

13. How do you measure pulse rate in a patient with a short pulse?

To measure the pulse rate of a patient with a short pulse, two people should take the measurement at the same time. One person should listen to the heart rate and the other person should measure the pulse rate, and both people should start at the same time, and the person who listens to the heart rate should give the command "start" and "stop", and then time the measurement for one minute.

14. What are the precautions for measuring blood pressure?

(1) Regular testing and calibration of the sphygmomanometer.

(2) For those who need to closely observe the blood pressure, they should do four things, namely, set the time, set the part, set the position, set the sphygmomanometer.

(3) When blood pressure is found to be inaudible or abnormal, it should be retested.

(4) Pay attention to the error of blood pressure measurement caused by the pressure measuring device (sphygmomanometer, stethoscope), the measurer, the examinee, and the measuring environment, in order to ensure the accuracy of blood pressure measurement.

15. What is the effect of a loose or tight cuff on blood pressure when measuring the most blood pressure?

(1) If the cuff is wrapped too loosely, the air bag is ballooned and the effective measurement area becomes narrower, resulting in higher blood pressure values.

(2) The cuff is wrapped too tightly, so that the blood vessels are pressurized before gas injection, and the measured blood pressure value is low.

16. What is tidal breathing?

Tidal breathing refers to breathing from shallow and slow to deep and fast, and then from deep and fast to shallow and slow, after a period of respiratory pause (5^-3. seconds), and then repeat the above cycle of respiration, week after week like the ebb and flow of the tide.

17. What are the contraindicated parts of cold therapy? Why?

(1) Post-occipital, auricle, scrotum: to prevent frostbite.

(2) precordial area: to prevent reflex slowing of heart rate, atrial fibrillation or atrioventricular block.

(3) Abdomen: to prevent diarrhea0

(4) Plantar: to prevent reflex peripheral vasoconstriction that affects heat dissipation or causes transient coronary artery constriction.

18. What are the contraindications to heat therapy?

(1) Acute abdominal pain without a clear diagnosis.

(2) Infection in the danger triangle of the face.

(3) Bleeding from various organs.

(4) The initial stages (within 48h) of a soft tissue injury or sprain.

(5) Skin eczema.

(6) Acute inflammatory reactions, such as dental achalasia, otitis media, and conjunctivitis.

(7) Metal graft sites.

(8) Malignant lesion sites.

19. What should be assessed before nasal feeding?

(1) Whether the gastric tube is in the stomach and clear, make sure the tube is in the stomach before injecting.

(2) Whether there is gastric retention, if the pumped gastric contents >100ml, then suspend nasal feeding.

20. What is the normal 24h urine output? What is polyuria, oliguria, and anuria?

A normal person's 24h urine volume is about 1000-2000ml, with an average of 1500ml.

Polyuria: refers to the 24h urine volume is often more than 2500ml.

Oliguria: refers to the 24h urine volume is less than 400ml or the urine volume per hour is less than 17ml.

Anuria: is also known as urinary closure, refers to the 24h urine volume is less than 100ml or within 12h urine volume is more than 100ml. Less than 100ml or no urine in 12h.

21. Briefly describe the method of collection of 24h urine specimen.

(1) Empty the bladder at 7:00 a.m. Thereafter, all urine is collected in a large clean container (such as a clean sputum Meng) until 7:00 a.m. the next morning, the last urine is drained into the container, the total amount of urine is measured and recorded on the laboratory form.

(2) Mix all the specimens well, take out about 20 ml of specimens from them, and put them in a clean and dry container to send for examination as soon as possible.

(3) For some special tests, preservatives are added as appropriate.

22. What are the common pathologic changes in urine color?

(1) hematuria: the shade of the color is related to the amount of red blood cells contained in the urine, the amount of red blood cells contained in the wash water color.

(2) hemoglobinuria: a large number of red blood cells are destroyed in the blood vessels, showing a strong tea color, soy sauce-like color.

(3) Bilirubinuria: the urine is dark yellow or yellowish brown, and the foam is also yellow after oscillating the urine.

(4) Celiac disease: urine contains lymphatic fluid and is milky white.

(5) Pus urine: urine contains pus, white flocculent turbid and can be seen containing pus filaments.

23. What are the nursing measures for acute urinary retention?

(1) Relieve the cause.

(2) promote urination: for postoperative patients with urinary retention to give induction of urination, if necessary, catheterization under aseptic operation, and good care of the urinary catheter and urethral orifice. For suprapubic cystocentesis or suprapubic cystostomy patients, do a good job in the care of the cystostomy tube and keep it open.

(3) Avoid bladder bleeding: the amount of urine released at one time should not exceed 1000ml to avoid bladder bleeding.

24. What are the key points of skin care for patients with urinary incontinence?

(1) Keep the bed sheet clean, flat and dry.

(2) Clean the perineal skin in a timely manner, keep it clean and dry, and apply skin protectant if necessary.

(3) according to the condition of the corresponding protective measures, male patients can use urinary condom, female patients can use urinary pads, urinary collector or indwelling urinary catheter.

25. What are the principles that should be followed when administering drugs?

(1) according to the requirements of the doctor to accurately give the drug: strict implementation of the doctor's orders, the doctor's orders should be clear understanding of doubt before giving the drug, to avoid blind implementation.

(2) Strict implementation of the "three checks and seven pairs" system.

(3) Safe and correct administration of drugs: rational control of the time and method of administration of drugs, drugs ready for timely distribution and use. Before giving medication to explain and give guidance on the use of medication. For drugs that are prone to allergic reactions, understand the history of allergy before use.

(4) Observation of drug reactions: drug efficacy, adverse reactions, changes in the patient's condition, dependence on drugs, emotional reactions.

26. What are the precautions when administering drugs orally?

(1) need to swallow the drug is usually taken with 40 a 60 ℃ warm boiled water, do not use tea to take drugs.

(2) on the tooth step has a corrosive effect of drugs, such as acids and iron, should be sucked after the straw rinse mouth to protect the teeth.

(3) Slow-release tablets, enteric-coated tablets, capsules should not be chewed when swallowed.

(4) Sublingual tablets should be placed under the tongue or between the membranes of the cheeks and the teeth to be dissolved.

(5) Antibiotics and sulfonamides should be taken punctually to ensure effective blood levels.

(6) It is not advisable to drink water immediately after taking drugs that have a calming effect on the respiratory mucosa. Information from ICU Nursing Home WeChat public **** number, please pay attention.

(7) Some sulfonamides are excreted by the kidneys, and crystals are easily precipitated to block the renal tubules when urine is scarce, so drink more water after taking the drug.

(8) In general, gastric drugs should be served before meals, digestive drugs and drugs that stimulate the gastric mucosa should be served after meals, and hypnotic drugs should be served before bedtime.

27. What are the precautions for oral iron therapy?

(1) In order to minimize gastrointestinal reactions, it can be taken after meals or during meals, starting with a small dose and gradually increasing to the full amount.

(2) Liquid iron can stain teeth black, can be taken with a straw or dropper.

(3) Iron can be taken with vitamin C;, fruit juice, etc., to facilitate absorption; avoid taking with foods that inhibit iron absorption.

(4) After taking iron, the stool becomes black or tarry. Recovery after stopping the drug, should explain the reason to the patient to eliminate concerns.

(5) Take the medication according to the dose and regimen, and review relevant laboratory tests regularly.

28. What kinds of oral care solutions are commonly used? What is the function of each?

Physiological saline to clean the oral cavity, the top anti-infection;

1% a 3% hydrogen peroxide solution antiseptic, anti-odor, for oral infections with ulceration, necrotic tissue

1% a 4% sodium bicarbonate solution alkaline solution for fungal infections

0.02% chlorhexidine solution to clean the oral cavity, broad-spectrum antimicrobial

0.02% chlorhexidine solution, broad-spectrum antibacterial

0.02% chlorhexidine solution to clean the oral cavity, broad-spectrum antibacterial

0.02% furacilin solution for oral cleansing, broad-spectrum antibacterial

0.1% acetic acid solution for Pseudomonas aeruginosa infections

2%-3% n boric acid solution acidic antiseptic, antibacterial

0.08% metronidazole solution for anaerobic bacterial infections

29. What types of oxygen therapy are available? For which type of patients is each indicated?

(1) low concentration oxygen therapy: oxygen concentration <40%. Applicable: patients with hypoxemia with carbon dioxide storage, such as chronic obstructive pulmonary disease.

(2) medium concentration oxygen therapy: oxygen concentration of 40% to 60% 0 for patients with significant ventilation / perfusion ratio imbalance or significant diffusion impairment, such as pulmonary edema, myocardial infarction, shock, etc..

(3) high concentration oxygen therapy: oxygen concentration >60% or more. Applicable to patients with simple hypoxia without carbon dioxide storage, such as adult respiratory distress syndrome, life support phase after cardiopulmonary resuscitation.

(4) Hyperbaric oxygen therapy: refers to the inhalation of 100% oxygen at a pressure of 2-3 kg/cm2 in a special pressurized chamber, e.g., carbon monoxide poisoning, gas gangrene.

30. Briefly describe the precautions for oxygen therapy.

(1) Emphasize the etiology.

(2) Keep the airway open.

(3) Choose the appropriate type of oxygen therapy.

(4) Pay attention to humidification and warming.

(5) Regularly change and clean dip sterilization to prevent contamination and catheter blockage.

(6) Evaluation of the effectiveness of oxygen therapy.

(7) Prevention of explosion and fire.

31. How to convert oxygen concentration to oxygen flow?

Oxygen concentration (%)=21+4*oxygen flow rate (L/min)

32. What are the precautions for oxygen nebulization inhalation?

(1) shoot the correct use of oxygen supply devices, pay attention to the safety of oxygen, oxygen humidification bottle do not hold water, so as not to be diluted to affect the efficacy of the drug.

(2) nebulization to guide the patient with a long deep inhalation through the mouth after holding the breath for 1 - 2 seconds, nasal exhalation, oxygen flow 6-8L/min.

(3) pay attention to observe the patient's sputum discharge situation, nebulization to assist the patient to clean the oral cavity.

33. What are the clinical manifestations of penicillin anaphylaxis?

(1) respiratory obstruction symptoms: manifested as chest tightness, shortness of breath with a sense of dying.

(2) Circulatory failure symptoms: manifested as pallor, cold sweat, issued, weak pulse, blood pressure drop, irritability.

(3) Central nervous system symptoms: manifested as dizziness, numbness of the face and limbs, loss of consciousness, convulsions, incontinence and so on.

(4) Other allergic reactions: urticaria, nausea, vomiting, abdominal pain and diarrhea.

34. Briefly describe the emergency care measures for penicillin anaphylaxis.

(1) Discontinue the medication immediately and make the patient lie down on the spot.

(2) Immediately inject 0.1% epinephrine hydrochloride subcutaneously. 0.5-1 ml, patient discretion. If the symptoms are not relieved, the drug can be injected subcutaneously or intravenously 0.5 ml every 30 min.

(3) Oxygen inhalation. When respiration is inhibited, mouth-to-mouth artificial respiration should be carried out immediately and intramuscular injection of respiratory anesthesia mixture. When laryngeal edema affects respiration, tracheal intubation should be prepared immediately or tracheotomy should be performed in conjunction.

(4) Anti-allergy.

(5) Correction of acidosis and administration of antihistamines as prescribed.

(6) If cardiac arrest occurs, immediately perform cardiopulmonary resuscitation.

(7) Closely observe the vital signs, urine output and other changes in the condition, pay attention to warmth, and make a good record of the dynamic condition. Patients should not be moved before they are out of danger.

35. How are venipuncture tools categorized?

According to the type of vessel in which the catheter is placed, it can be divided into: peripheral venous catheter, central venous catheter. The length of the catheter can be categorized as: short catheter, medium length catheter, long catheter.

36. How to flush and seal an indwelling intravenous catheter?

(1) Method of flushing: The flushing solution is usually saline, using a pulsatile flushing method. Peripheral indwelling needle can use 5ml syringe for flushing; picc catheter should be more than 10ml syringe for flushing. The minimum amount of flushing fluid should be two times the volume of the catheter and add-on device.

(2) sealing method:

① steel needle method: leave the tip of the needle in the heparin cap a little, pulse push sealing liquid left 0.5-1ml, while pushing sealing liquid, while pulling the needle (push liquid speed is greater than the speed of pulling the needle), to ensure that the indwelling catheter is full of sealing liquid, so that there is no medicine or blood in the catheter.

② needleless connector method: punch the tube before removing the syringe will be as close as possible to the puncture point of the small clip, clip after the small clip to remove the syringe.

37. What are the clinical manifestations of common infusion reactions?

(1) feverish reaction: most of the factory infusion minutes to 1 hour. The performance of chills, chills, fever. In mild cases, the body temperature is about 38 ℃, and can return to normal within a few hours after stopping the infusion; in severe cases, chills at the beginning, followed by high fever, body temperature up to 40 ℃ or more, and accompanied by headache, nausea, vomiting, rapid pulse and other systemic symptoms.

(2) acute pulmonary edema: the patient suddenly appeared dyspnea, chest tightness, cough, cough pink foamy sputum, severe sputum can be gushed from the mouth, nasal cavity. Auscultation of the lungs is covered with wet gong sounds, and the heart rate is fast and arrhythmic.

(3) Phlebitis: streaks of red lines along the veins, local tissue redness, swelling, burning, pain, sometimes accompanied by chills, fever and other systemic symptoms.

(4) Air embolism: the patient feels abnormal discomfort in the chest or has retrosternal pain. Dyspnea and severe emanation with a sense of imminent death occur immediately. On auscultation, a loud, persistent "blistering sound" can be heard in the precordial area.

38. Briefly describe the causes and management of acute pulmonary edema during infusion.

Causes:

(1) Infusion rate is too fast, too much fluid is infused in a short period of time, so that the circulating blood volume increases dramatically and the heart is overloaded.

(2) The patient's original cardiopulmonary dysfunction.

Treatment measures:

(1) Immediately stop the infusion and notify the doctor for emergency treatment. If the condition permits, the patient can be made to sit up, legs down, in order to reduce the venous return of the lower limbs, reduce the burden on the heart.

(2) Give the child high-flow oxygen inhalation, the general oxygen flow of 6-8L/min. At the same time, humidification bottle with 20% - 30% ethanol solution.

(3) Follow the medical advice to give sedation, asthma, cardiac, diuretic and vasodilator drugs.

(4) If necessary, carry out limb rotation tie. Rubber tourniquet or sphygmomanometer cuff appropriate pressure to block venous blood flow, every 5-10min rotation relaxation of a limb tourniquet, can effectively reduce the venous return blood volume. After the symptoms are relieved, the tourniquet is gradually lifted.

39. What position should the patient take when air embolism occurs during infusion? Why?

The patient should be placed in the left lateral position with the head down and feet up. This position allows the gas to float to the right ventricular apex, avoiding the pulmonary artery population, and with cardiac contraction and expansion, the air is mixed into bubbles that enter the pulmonary artery in small amounts and are gradually absorbed.

40. What are the precautions in the use of mannitol?

(l) It is strictly prohibited for intramuscular or subcutaneous injection, to avoid drug leakage caused by subcutaneous edema or tissue necrosis.

(2) Can not be mixed with other drugs IV.

(3) When intravenous drip, it is appropriate to use a large needle, 250ml of liquid should be completed within 20-30min.

(4) In the process of applying dehydrating agent, the amount of discharge, blood pressure, pulse, respiration should be closely observed and recorded.

(5) can make the blood volume increase rapidly, cardiac insufficiency and acute pulmonary edema patients are prohibited.

41. According to the type of antigen on the red cell membrane. What are the blood types?

(1) Type A: only A antigen on the red blood cell membrane.

(2) Type B: those who have only B antigen on the red blood cell membrane.

(3) AB type: those who have both A and B antigens on the erythrocyte membrane.

(4) Type O: those who have neither A nor B antigens on the red blood cell membrane.

42. What are the precautions for component blood transfusion?

(1) Some components of blood, such as white blood cells, platelets, etc. (except red blood cells), short survival period, fresh blood is preferred, and must be transfused into the body within 24h (from the start of blood collection time).

(2) In addition to plasma and albumin preparations, a variety of other components of blood need to be cross-matched before transfusion.

(3) Antiallergic drugs are given according to medical advice before transfusion.

(4) If the patient needs to be transfused with whole blood at the same time as the component blood, then the component blood should be transfused first, followed by the whole blood. Then the component blood should be transfused first, followed by whole blood, to ensure that the component blood can play the best effect.

43. What are the common transfusion reactions?

① fever reaction;

② allergic reaction;

③ hemolytic reaction;

④ massive transfusion reaction;

⑤ bacterial contamination reaction;

⑥ disease infection and so on.

44. How to deal with allergic reaction in blood transfusion?

(1) Mild allergic reaction, slow down the speed of blood transfusion, give anti-allergic drugs.

(2) moderate and severe allergic reaction, should immediately stop blood transfusion, subcutaneous injection of 0.1% epinephrine. 0.5-1ml, intravenous injection of dexamethasone and other anti-allergic drugs.

(3) Those with respiratory distress are given oxygen inhalation, and tracheotomy is performed for severe laryngeal edema.

(4) circulatory failure, give anti-shock treatment.

45. What are the causes of hemolytic reaction in blood transfusion? How to deal with it?

Causes:

(1) Entered a different type of blood.

(2) Deteriorated blood is imported.

(3) Hemolysis due to Rh factor.

Treatment:

(1) Stop the transfusion immediately and notify the doctor.

(2) Give oxygen inhalation, establish venous access, and give pressor-boosting drugs or other medications as prescribed by the doctor.

(3) Send the remaining blood, the patient's blood specimen and urine specimen to the laboratory for testing.

(4) Bilateral lumbar closure and hot compresses with hot water bags on bilateral renal areas to relieve renal tubular spasm and protect the kidneys.

(5) Alkalize the urine: intravenous sodium bicarbonate solution.

(6) Closely observe the vital signs and urine output, insert a catheter, test the hourly urine output and keep a record.

(7) If there are symptoms of shock, anti-shock treatment should be carried out.

(8) Psychological care: comfort the patient, eliminate their nervousness and fear.

46. What is the main content of the condition observation?

(1) general observation: development and body shape, diet and nutritional status, face and expression, body position, posture and gait, skin and mucous membranes.

(2) Observation of vital signs.

(3) Observation of state of consciousness.

(4) Observation of pupils.

(5) Observation of the mental state.

(6) Observation of special tests or medication.

(7) Observation of secretions, excretions and vomit.

47. How to determine different degrees of impaired consciousness?

(1) Drowsiness: the mildest degree of impaired consciousness. The patient is in a persistent state of sleep, but can be awakened by words or mild stimulation, and can answer questions correctly, simply and slowly after waking up, but the response is slow, and after stopping the stimulation, the person will fall asleep again very soon.

(2) fuzzy consciousness: its degree is deeper than sleepiness. It is characterized by disorientation, incoherent thinking and language, delusion, hallucination, restlessness, delirium or insanity.

(3) lethargy: the patient is in a state of sleep, not easy to wake up. But can be pressed on the supraorbital nerve, shaking the body and other strong stimulus to wake up, after waking up to answer vague or non-answer, after stopping the stimulation and then into a state of sleep.

(4) Shallow coma: most of the loss of consciousness, no voluntary activities, no response to light, sound stimulation, pain stimulation can have a painful expression or limb flinch and other defensive reactions.

(5) deep coma: complete loss of consciousness, no response to various stimuli.

48. How to determine the size of the pupil?

Under natural light, the diameter of the pupil is 2-5mm, with an average of 3-4mm.

Pathologically, the diameter of the pupil is less than 2mm for the pupil to shrink, and less than Imm for the pinpoint pupil. Pupil diameter greater than 5 mm is dilated.

49. What are the clinical manifestations of deep vein thrombosis of the lower extremities? How can it be prevented?

Clinical manifestations:

(1) Swelling of the affected limb, accompanied by increased skin temperature.

(2) Localized sharp pain or pressure pain.

(3) Positive Humans' sign, with severe pain in the calf on the stomping joint hyperflexion test.

(4) Dilatation of superficial veins.

Preventive measures:

(1) Appropriate exercise to promote venous return. Long-term bedridden and braked patients, to strengthen the bed movement; postoperative patients early out of bed activities; blood in a state of high coagulation, can be preventive application of anticoagulant drugs.

(2) Protection of the veins: long-term infusion, should try to protect the veins, to avoid repeated puncture in the same place. Try to avoid venous infusion in the lower extremities.

(3) Quit smoking.

(4) Eat a low-fat, high-fiber diet and keep the bowels clear.

50. What are the basic principles that should guide nursing documentation?

(1) Timely: Nursing records must be timely, not delayed or early, and can not be omitted,

Wrong record, to ensure that the record of the timeliness. If you fail to record in time due to rescue, you should make up the record within 6h after the end of the rescue, and indicate the completion of the rescue and make up the time.

(2) Accurate: the content is true and error-free, and the time recorded should be the actual time of drug administration, treatment, and care.

(3) complete: the eyebrow column, page number must be filled out completely. The record is continuous, not leave empty since. Sign your full name after each record.

(4) Brief: focused, concise, fluent, using medical terminology and recognized abbreviations.

(5) clear: according to the requirements of the use of red and blue pen writing, handwriting is clear, the font is correct, keep neat, not to alter, cut and paste and the abuse of simplified characters

Nurses basic nursing knowledge 2

The nurse is the most basic to master the basic knowledge of the following five:

First, a certain degree of cultural cultivation, nursing theory and knowledge of the humanities, as well as participation in nursing education and nursing research basic knowledge. Competent nursing work, and the courage to study business technology, to maintain a high level of care.

II. Strong nursing skills and the ability to apply the working methods of the nursing program to solve existing or potential health problems of patients.

Third, a healthy mind, cheerful, stable emotions, tolerance and open-mindedness, robust physical fitness. Work style is rigorous and subtle, proactive, decisive, agile and pragmatic.

Fourth, pay attention to civilized manners, standardized terminology, amiable attitude, steady and dignified, neat clothing, generous instrument.

Fifth, have good medical ethics, integrity and public service. Do not do against the moral conscience of the illegal operation or disloyal work to maintain the reputation of the profession.

Expanded:

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The nurse's work content:

1, can not violate the rules of operation, labor insurance wear neatly, the implementation of basic and specialized nursing routines, nursing technical operation procedures and related regulations.

2, to assist the doctor to do a good job on the patient and his family consultation, counseling, reception and treatment. The patient should have a high degree of sympathy, considerate and loving, active and enthusiastic, friendly expression, speak gently, work patiently and meticulously, ask questions and answer them, do not argue with the patient.

3, the implementation of medical advice and nursing technical operations. Pay attention to patrol, observe the condition and infusion situation, find abnormalities timely report to the physician; to assist in the treatment of new, surgical, emergency and critical patients; responsible for blood preparation, blood collection, escorting critically ill patients out for examination.

4, regular in-depth ward and patient communication, in order to obtain information about the patient's condition, to understand the patient's concerns, to solve the patient's problems in a timely manner, to give psychological support and humanistic care.

5, to strengthen the medical and nursing new knowledge of learning, focusing on learning the relevant knowledge of the room. Each patient's condition of the room medication treatment know as well as in the treatment and care check, to do a few. Once the error, can be found early, accurate judgment.

6, responsible for the management of medical documents and goods, do a good job of inventory handover. After work, do a good job of cleaning and hygiene and the next day's work in advance, to maintain a clean and beautiful working environment. Timely reporting, reflecting the views of patients on hospital services and requirements, and make records.

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