特級護理質(zhì)量考核標(biāo)準(zhǔn)

特級護理質(zhì)量考核標(biāo)準(zhǔn),,,

序號,檢查內(nèi)容,存在問題,分值

1,標(biāo)識1.0,1.1床頭卡未標(biāo)記，標(biāo)記不清，有涂改，標(biāo)記有誤,0.25

,,1.2一覽卡未標(biāo)記，標(biāo)記不清，有涂改，標(biāo)記有誤,0.25

,,1.3溫馨提示卡未按要求,0.25

,,1.4患者未佩戴腕帶、腕帶相應(yīng)顏色不正確、患者信息字跡不清、有涂改、無手術(shù)名稱,0.25

2,床單元1.0,2.1病床不整潔，如床體有血漬、污漬，未按要求終末消毒,0.2

,,2.2病床有不安全因素，如床鎖、床檔、搖把等配件損壞未報修,0.2

,,2.3床單不整潔、不干燥、不平整、未將床墊包上,0.2

,,2.4床上有多余物品,0.1

,,2.5床下有多余物品，便器里有剩余尿液未倒凈,0.1

,,2.6床頭桌不整潔,0.1

,,2.7輸液架不整潔,0.1

3,功能帶1.0,3.1吸痰、吸氧裝置損壞未及時報修或未有警示標(biāo)識,0.25

,,3.2一次性吸痰器、氧氣濕化瓶用后未撤除,0.25

,,3.3功能帶有灰塵或存在膠布痕跡,0.25

,,3.4功能帶存在非醫(yī)療用品,0.25

4,患者1.0,4.1患者（根據(jù)病情）未穿病人服,0.2

,,4.2非探視時間有家屬探視,0.2

,,4.3有家屬自帶陪床,0.2

,,4.4胡須長、批（趾）甲長,0.2

,,4.5頭發(fā)、面部、皮膚、手足、口腔、會陰不清潔，有異味、有血、尿便及膠布痕跡,0.2

5,記錄單1.0,5.1無重癥患者記錄單,0.1

,,5.2提前記錄、未及時記錄,0.1

,,5.3生命體征記錄不準(zhǔn)確（如起搏心率記錄次數(shù)不準(zhǔn)確）,0.1

,,5.4生命體征記錄與體溫單不符,0.1

,,5.5監(jiān)測指標(biāo)記錄不準(zhǔn)確、與病情不符,0.1

,,5.6護理記錄與醫(yī)生病程記錄不符,0.1

,,5.7未按護理文件書寫規(guī)范記錄,0.1

,,5.8護理等級量表、高?；颊咴u估單示及時評估,0.1

,,5.9記錄單有涂改,0.1

,,5.10記錄單未簽字、未蓋章,0.1

6,管路1.0,6.1各種管路未有標(biāo)識、標(biāo)識不清,0.2

,,6.2各種管路固定不妥善、不潔、脫管、堵管,0.2

,,6.3各種管路、引流袋（盒、球）放置位置不當(dāng),0.2

,,6.4各種引流袋、盒未按要求及時更換,0.2

,,6.5各種引流液未及時倒掉,0.2

序號,檢查內(nèi)容,存在問題,分值

7,儀器1.0,7.1各種儀器設(shè)備未處于良好備用（使用）狀態(tài),0.2

,,7.2儀器故障未及時報修,0.1

,,7.3各種搶救儀器不能熟練掌握操作步驟,0.2

,,7.4各種儀器設(shè)備不能處理報警、故障,0.1

,,7.5各種儀器設(shè)備不清潔（表面、連接線、導(dǎo)線、血氧飽和度探頭、袖帶、管路等）,0.2

,,7.6儀器、設(shè)備未及時消毒、更換（呼吸機管路、潮化罐、超聲霧化器、吸氧潮化瓶等）未設(shè)有維修記錄本、使用記錄本，記錄不及時,0.2

8,護理1.0,8.1示正確、及時執(zhí)行醫(yī)囑的各項護理（如吸氧、霧化、鼻飼、吸談、換藥、口護、尿、護、氣切護理等）,0.025

,,8.2眼瞼不閉合未有處理措施,0.025

,,8.3患者口唇干裂未護理,0.025

,,8.4躁動、昏迷、不能處理患者無安全措施,0.025

,,8.5約束帶臟、使用不當(dāng)，無知情同意書,0.025

,,8.6未及時發(fā)現(xiàn)護理問題：1液體外滲，2輸液反應(yīng)，3液體出入量不平衡，4輸液結(jié)束未及時更換等,0.025

,,8.7患者未保持良好的功能體位，如防止誤吸的體位、防止足下垂的體位等,0.025

,,8.8翻身時各種管路未給予保護,0.025

,,8.9翻身時傷口未給予保護,0.025

,,8.10未根據(jù)病情定時翻身、叩背、觀察受壓部位皮膚情況,0.025

,,8.11冷、熱護理不合理,0.025

,,8.12臥床患者褥瘡好發(fā)部位未有預(yù)防措施、無風(fēng)險評估記錄單,0.025

,,8.13傷口敷料未包扎完好未及時處理,0.025

,,8.14傷口敷料（如氣管切開敷料）未及時更換,0.025

,,8.15傷口周圍未給予保護,0.025

,,8.16血壓計袖帶未縛于正確位置，松緊不適宜（肢體有輸液、動靜脈瘺、患肢等禁止時行測量血壓）,0.025

,,8.17血氧飽和度探頭未定時更換所夾部位,0.025

,,8.18靜脈注射速度與醫(yī)囑不符,0.025

,,8.19用過的注射器放在床頭柜上,0.025

,,8.20鼻飼速度過快,0.025

,,8.21鼻飼飲食溫度不適宜、鼻飼管內(nèi)有鼻飼液積存，未及時沖洗,0.025

,,8.22吸痰不及時,0.025

,,8.23吸痰時違反無菌操作,0.025

,,8.24吸痰操作不正規(guī),0.025

,,8.25氣管（氣切）插管氣囊壓力過高（低）,0.025

,,8.26氣管（氣切）插管未及時放氣囊,0.025

,,8.27氣管插管深度改變未有護理措施,0.025

序號,檢查內(nèi)容,存在問題,分值

8,護理1.0,8.28氣切導(dǎo)管內(nèi)套管未及時消毒,0.025

,,8.29人工鼻使用不正確,0.025

,,8.30輸液速度與病情、藥物說明不符、與記錄不符,0.025

,,8.31輸入需避光藥物未避光,0.025

,,8.32床旁未備手消液，手消液未注明開啟日期,0.025

,,8.33各項操作結(jié)束前后未及時洗手，有交叉感染可能,0.025

,,8.34病情變化未及時發(fā)現(xiàn),0.025

,,8.35病情變化時未有處理措施,0.025

,,8.36未床頭交接班,0.025

,,8.37床頭交接班不清楚、有遺漏,0.025

,,8.38未掌握患者病情,0.025

,,8.39未掌握患者異?；?0.025

,,8.40配合醫(yī)生各項操作、搶救不到位,0.025

9,治療1.0,9.1未及時、正確的執(zhí)行醫(yī)囑,0.15

,,9.2輸入藥物未合理安排（時間、順序、滴速、方法）,0.1

,,9.3輸液部位不規(guī)范，存在下肢靜脈穿刺、關(guān)節(jié)部位穿刺,0.15

,,9.4未掌握治療藥物的藥理作用,0.1

,,9.5未掌握治療藥物的目的,0.1

,,9.6未備齊急救藥品,0.1

,,9.7