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1、1 护理突发事件应急预案（一）定义：护理突发事件是指超出常规的、无法预料而突然发生的与护理相关的事件。如：患者跌倒坠床、烫伤、病人外送途中意外、群体腹泻事件、走失、自杀等。（二）成立护理突发事件应急工作组：组长：姜汉斌副组长：李新珍组员：各科护士长1.组长工作职责（1）组织制定、修订突发事件应急预案，完善各专项预案；（2）协助开展突发公共卫生事件医疗护理救助演练；（3）监督、指导各护理站开展应对突发事件的各项准备工作。组织开展各类护理应急管理、护理应急知识、护理应急处理技术等培训和演练；（4）负责护理应急方面的重大问题决策，包括人员、设备、药品的调动等；（5）具体指挥护理突发事件工作组有序工作
2、，随时针对具体问题，采取相应的应急措施；（6）协调相关职能科室积极配合抢救；（7）随时向医疗救护领导小组组长汇报预案执行实际情况，供组长决策。2.护理突发事件应急工作组成员职责（1）在护理突发事件应急工作组组长的指挥下开展工作；（2）认真学习贯彻医院应急预案，负责各种护理突发事件的现场处置工作，并按相关的规定及时实施各种护理救助；（3）平时坚持学习与各类突发事件相关的专业知识和技能；（4）各成员必须保证通讯24 小时畅通；（5）负责及时将现场处置情况报告护理突发事件工作组组长，为组长的决策提供依据；（6）对突发情况处置完毕后进行总结，不断完善应急抢救预案。（三）部分护理急救应急预案1.住 院
3、患 者 压 疮 预 案患者住院期间护理人员必须对其进行压疮风险评估，根据评估情况针对性的采取预防措施。发生压疮的处理措施：在采取下列措施后汇报护理部，填写护理不良事件报告单，必要时请护理会诊。更换体位，落实预防措施。皮肤红润或表皮破损：贴透明贴。浅表溃疡或坏死组织溃疡期：换药流程（每1-2天一次）处理程序：2 评估清创无菌生理盐水冲洗根据情况选择用药：溃疡贴、优赛、泡沫贴、清创胶、银离子敷料等纱布覆盖。水泡者：用无菌注射器抽出水泡内液体，局部消毒后用无菌敷料包扎。配合理疗，如红外线照射等。2.住院患者跌倒预案（1）风险评估、与预防措施（2）发生跌倒或坠床立即通知医生初步评估患者病情，神智、瞳孔
4、、肢体活动、生命体征的变化，检查有无伤口，有无头部着地汇报护士长、护理部、填写意外事故报告单，必要时报告医院总值班持续加强跌倒宣教，病人、家属加深预防跌倒意识，记录患者坠床/跌倒的过程及抢救措施年老体弱、行动不便、步态不稳、神志障碍、等身体虚弱病人为高危跌倒人群护士填写“跌倒高危因素评估单”对家属进行跌倒宣教，并请家属签名。床头牌上插“小心跌倒”警示标识开出陪护医嘱，落实其他跌倒预防措施（提供安全环境，保持病区地面干燥，有防滑标识）护理记录单记录文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q
5、9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T
6、8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q
7、9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T
8、8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q
9、9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T
10、8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q
11、9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I13 3.住院患者烫伤预案（1）风险评估昏迷、老人、婴幼儿、感觉迟钝、麻醉未清醒、循环不良等患者存在烫伤风险。（2）落实烫伤预防措施告知热疗目的、方法、注意事项。使用热水袋：a.检查热水袋有无破损，热水倒入1/2 2/3 量；拧紧盖子，防漏水。b.温度：成人 6070,昏迷、老人、婴幼儿、感觉迟钝、麻醉未清醒、循环不良等患者水温调至 50。c.热水袋外有布套，不直接接触患者皮肤。d.特殊患者热水袋外再用毛巾包裹，或夹在两层毯子中间。正确掌握 TDP神灯，微波炉、开水炉等方法、距离。经常巡视观察皮肤颜色，严格
12、执行交班制度。（3）发生烫伤立即停止使用热疗根据烫伤情况及时正确处理伤口（如涂湿润烧伤膏）汇报护理部填写护理不良事件报告单护理记录单上记录，必要时请护理会诊文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1
13、X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档
14、编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1
15、X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档
16、编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1
17、X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档
18、编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I14 4.精神异常患者应急预案（1）患者发生精神异常时，立即采取安全保护措施，以免患者自伤或伤及他人。（2）立即通知医生和护士长，夜间通知总值班。（3）协助医生通知患者家属，做好解释工作。（4）24 小时设
19、专人陪护。（5）如果患者行为过激时，应通知保卫科或相关部门，协助处理。（6）协助医生请专科会诊。（7）遵医嘱给予药物治疗或转院。（8）记好护理记录。5.病人在运送过程中意外防范预案（1）风险因素：环境、硬件方面：a.运输病人途中，通路不平整。b.运输工具：平车、轮椅不符合要求（零、部件坏损未及时修理）发现患者出现精神异常后采取必要的安全保护措施，防止患者手上，同时保护同病室患者及家属立即通知医生及护士长夜间通知总值班设专人陪护协助通知患者家属协助医生请专科会诊根据患者精神症状的表现遵医嘱给予药物治疗或送专科医院治疗做好护理记录文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8
20、Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5
21、T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8
22、Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5
23、T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8
24、Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5
25、T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8
26、Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I15 c.在运输途中，病情发生变化时，未准备抢救物品。思想、技术方面：a.医务人员责任心不强：上班思想不集中，工作马虎等。b.专业知识匮乏：搬运方法不正确、对病区不了解，不能及时发现病情变化以及预计潜在的不安全因素等。c.运送途中，静脉通路不通畅，不能及时有效的给药。d.没有保证有效的供氧。e.搬运过程中，中间衔接不紧密。病人方面：由于病人自身的因素：如病人意识不清、烦躁不安。（2）防范措施：医院内各道路平整，运输过程中保持平
27、稳，以防颠簸加重病情。发现问题及时通知后勤。运输工具由专人负责、定期维修。运送前检查是否完好无缺。担架车要用护栏，轮椅系上安全带。根据病情，准备相应的抢救物品。如气管插管、简易呼吸器、便捷式小氧气筒、抢救药物等。加强护送者的责任心，护送到位。运送危重病人，一定要由有经验的护士护送；如为轻病人，可由经过培训的护工送，但一定要交代护送途中注意事项。加强护士素质教育，不断提高业务水平。有计划的培训急救技术，定期进行理论和操作考核。加强法制观念，依法行医，依法施护。对急诊病人，发现潜在的危险因素，防患于未然。保证氧气的有效供给，静脉通路的通畅和适合的滴速以及做好各种管道的护理。烦躁不安的病人应有专人看
28、护，必要时使用约束带，防止坠落伤。昏迷病人要头偏向一侧，防止呕吐引起的窒息。掌握正确的搬运方法和推车技巧，上、下坡时要把握好速度，护士站于病人头侧，便于观察病情，下坡时病人头部在高处一端。一旦发生坠落、身体擦伤等意外事故，应立即给予紧急处理，尽量把意外伤亡降低到最低。有家属的尽量能够取得家属的谅解，无家属的立即通知家属，同时汇报上级部门。6.导管脱落防范与应急处理 1 所有管道必须妥善固定，由置管者做好标记，详细记录管道名称、留置时间、部位、长度，观察和记录引流管引流液的性质、量，发现异常，及时处理。2 加强对高危患者（如意识障碍、躁动、有拔管史、依从性差的患者）的观察，作为重点交接班内容详细
29、交班。文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8
30、HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S
31、7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8
32、HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S
33、7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8
34、HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S
35、7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I16 3 做好患者及家属的健康教育，提高其防范意识及管道自护能力。4 严格遵守操作规程，治疗、护理中动作轻柔，注意保护导管，防止导管脱落。5 加强培训，提高护士防导管脱出移位的风险意识。如PICC 置管，穿刺时尽量避开肘窝，以透明敷料固定体外导管，也可使用固定翼加强导管固定；更换敷料时，避免将导管带出体外。【处理措施】根据脱落导管的类别采取相应的措施，查
36、找原因，作好记录和交接班，防止再次脱管。(1)伤口引流管脱落立即报告医师，将脱出的引流管交医师查看是否完整，如有管道断裂在体内，须进一步处理；观察伤口渗出情况，需要再次置管时，协助医师做好相关准备。(2)胸腔闭式引流管脱落引流管与引流瓶连接处脱落或引流瓶损坏，立即夹闭引流管并更换引流装置；引流管从胸腔滑脱，立即用手捏闭伤口处皮肤，通知医师并协助处理。(3)“T”管脱落立即报告医师，密切观察腹痛情况，告知患者暂禁食禁饮，必要时协助医师重新插管。(4)胃管脱落观察患者有无窒息表现，是否腹胀；如病情需要，遵医嘱重新置管。(5)导尿管脱落观察患者有无尿道损伤征象，是否存在尿急、尿痛、血尿等现象；评估患
37、者膀胱充盈度、是否能自行排尿，必要时遵医嘱重新置管。(6)气管导管脱落对气管切开患者立即用止血钳撑开气管切开出，确保呼吸道畅通，同时报告医师，给予紧急处理。(7)PICC置管深静脉置管脱落导管部分脱出：观察导管脱出的长度，用无菌注射器抽回血，如无回血。，报告医师，遵医嘱用肝素钠液或尿激酶通管，如导管不通畅则拔管；如有回血，用生理盐水冲管保持通畅，重新固定，严禁将脱出的导管回送。导管完全脱出：测量导管长度，观察导管有无损伤或断裂；评估穿刺部位是否有血肿及渗血，用无菌棉签压迫穿刺部位，直到完全止血；消毒穿刺点，用无菌敷贴覆盖；评估渗出液性状、量；根据需要重新置管。导管断裂：如为体外部分断裂，可修复
38、导管或拔管。如为体内部分断裂，立即报告医师并用止血带扎于上臂；如导管尖端已漂移至心室，应制动患者，协助医师在x 线透视下确定导管位置，以介入手术去除导管。(8)自控镇痛泵(PCA)导管脱落：立即检查导管末端是否完整，报告医师及麻醉师进行处理，密切观察病情及生命体征变化。发生脱管应急处理并报告医生文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5
39、Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4
40、V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5
41、Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4
42、V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5
43、Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4
44、V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I17 7.药物外渗预案（1）风险评估使用高刺激性药物如：化疗药、高
45、渗药、血管收缩剂-高度风险静脉条件差-可能风险（2）补液准备：首选大粗静脉、弹性好、避开关节；尽量避免选择下肢静脉，血管交替使用。穿刺用具尽量使用留置针。预防宣传：向病人、家属交待化疗药物注意事项；减少下肢肢体活动，加强看护；如有疼痛、输液不畅、局部肿胀等及时呼叫。高刺激性化疗药物建议深静脉置管或PICC置管。（3）按正规静脉输液流程执行预防性保护：a.使用化疗药物前后用生理盐水或其他补液滴入，确保血管内方可用药，强调一针见血，回血不畅重新建立静脉通道b.必要时按静脉走向行局部预防行湿敷：50%硫酸镁等。c.加强巡视，询问病人有无疼痛等不适。d.做好交接班，床边交接班。查看穿刺部位。（4）发生
46、药物外渗协助医生处理，必要时重新置管密切观察病情变化做好记录及交接班防止再次脱管立即停止输液文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5T8 HR3S1X6U9D6 ZY5Q8Q9S7I1文档编码:CO1I1C4V5
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