心外科手术室护理个案2

手术室护理个案精心呵护,珍惜每一次服务机会！这里可以简要de描述您de项目汇报人:xxx部门:心外科一病人信息目录二术前访视三术中配合四术后访视病人信息第一部分operatingroomnursingcasesoperatingroomnursingcasesroomnursingcasesoperatingroom用心服务健康珍惜每一次服务患者de机会！病人信息病案号:科别:病室:诊断:左后天性拇外翻麻醉方式:硬膜外麻醉手术名称:左拇外翻矫形复位内固定术术前访视第二部分operatingroomnursingcasesoperatingroomnursingcasesroomnursingcasesoperatingroom查阅病历:HBSAG阴性其他传染病:无既往病史:无手术史:做过“十二指肠脂肪瘤切除术”于中山医院做过阑尾切除术.过敏史:未发现术前评估:生命征:体温三六.五脉搏七六血压:一一八/六四沟通状况:好肢体运动障碍:无血管状态:充盈术前宣教:自我介绍,环境介绍术前需精神放松、密切配合术前禁食、水,去掉饰物、眼镜、假牙等介绍手术需配合事项如麻醉体位de配合特殊问题及注意事项:无术中配合第三部分operatingroomnursingcasesoperatingroomnursingcasesroomnursingcasesoperatingroom物品准备:电源安全、吸引装置等设备安全有效,手术物品包括普通不累骨科器械,电刀一,电烧片一,吸引器管一,二寸纱一,骨科纱一,刀片二,缝线三把,灭菌盐水帕一,中型敷贴,三-零VR,圆针一,角针一,七号手套二副,六号半手套二副.接到病人,根据手术通知单核对信息（科别:骨科病室:手术部位:左脚拇指麻醉方式硬膜外麻醉手术名称左拇外翻矫形复位内固定术）点收病人带至手术室de病历,检查病人术前皮肤准备情况,饰物等已取下.物品准备,核对病人零一零二零一零二零三零四零五帮助手术人员穿手术衣,暴露病人手术区,协助手术者消毒调整好照明光源接好电刀、吸引器等详细清点登记手术台上de器械敷料等数目,于术前、术中关闭体腔前及切口缝合前与器械护士共同清点、核对根据手术进展情况随时调整灯光供应术中所需物品（碘伏、针线等）,密切观察病情变化保证输液通畅,监督手术人员严格执行无菌技术操作.手术前给予头孢林挫钠一零零ml预防感染,手术前后给予万汶五零零ml,代斯五零零ml同时置电极板于右小腿处,一边电刀de正确使用给病人相关解释,消除恐惧、紧张心理.安置体位建立静脉通路安置体位,建立静脉通路根据麻醉方式及手术部位病人采取仰卧位,左手手背建立留置针静脉通路纱布缝针等数目穿无菌手术衣将各种物品分类术前准备术前二零min洗手、穿无菌手术衣、戴无菌手套,做好无菌桌de整理和准备工作纱布和缝针等数目,检查各种器械和敷料等物品是否齐全完好将各种物品分类,顺序摆放.协助医师做手术区皮肤消毒和铺手术单保持器械和用物de清洁保持手术野、器械托盘及器械桌de整洁、干燥和无菌物品de无菌状态,器械用毕后及时收回擦净,做好“快递,快收”,随时整理器械及用物排放整齐与巡回护士连接吸引器、电刀电源并固定手术区便于医师手术需要正确传递用物.术中按常规及术中情况向手术医生正确及时传递器械、纱布、缝针等用物.传递用物并整理手术间,准备下一台手术.随时清理缝线残端器械摆放妥善保管器械清洁分类放置术毕协助医师处理、包扎伤口,清点,处理手术器械术后访视第四部分operatingroomnursingcasesoperatingroomnursingcasesroomnursingcasesoperatingroom零一术后访视日期:术后第一天精神:可疼痛:有体温:正常伤口愈合:良好皮肤破损灼伤:无零二术后访视日期:术后第二天精神:疼痛:有体温:正常伤口愈合:良好皮肤破损灼伤:无零三皮肤破损灼伤:无患者、家属对手术室工作评价:满意患者家属对访视所持态度:欢迎医疗工作汇报ThistemplateisexclusivelydesignedbyFengyuncreativeandcopyrightsbelongtoFengyuninterneThistemplateisexclusivelydesignedbyFengyuncreativeandcopyrightsbelongtoFengyuninternettBUSINESSPLAN汇报:xxx部门:心外科CONTENTSThisisagoodspaceforashortsubtitle零一

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