五十项护理技术操作评分标准

./r/n./r/nWORD文档可编辑/r/n技术资料专业分享/r/n护理技术操作考核评分标准目录/r/n第一项一般洗手操作考核评分标准/r/n……/r/n3/r/n第二项无菌技术操作考核评分标准/r/n……/r/n4/r/n第三项生命体征监测技术操作考核评分标准/r/n…………/r/n5/r/n第四项口腔护理技术操作考核评分标准/r/n………………/r/n6/r/n第五项鼻饲技术操作考核评分标准/r/n……/r/n7/r/n第六项女病人导尿技术操作考核评分标准/r/n……………/r/n8/r/n第七项胃肠减压技术操作考核评分标准/r/n………………/r/n9/r/n第八项大量不保留灌肠技术操作考核评分标准/r/n………/r/n10/r/n第九项鼻塞〔鼻导管吸氧技术操作考核评分标准/r/n…/r/n11/r/n第十项换药技术操作考核评分标准/r/n……/r/n12/r/n第十一项雾化吸入技术操作考核评分标准/r/n………………/r/n13/r/n第十二项血糖监测技术操作考核评分标准/r/n………………/r/n14/r/n第十三项口服给药技术操作考核评分标准/r/n………………/r/n15/r/n第十四项密闭式输液技术操作评分标准/r/n………………/r/n16/r/n第十五项密闭式静脉输血技术操作考核评分标准/r/n………/r/n17/r/n第十六项静脉留置针技术考核评分标准/r/n…………………/r/n18/r/n第十七项静脉采集血标本技术操作考核评分标准/r/n………/r/n19/r/n第十八项静脉注射技术操作考核评分标准/r/n………………/r/n20/r/n第十九项动脉血标本的采集技术操作考核评分标准/r/n……/r/n21/r/n第二十项肌内注射技术操作考核评分标准/r/n………………/r/n22/r/n第二十一项皮内注射技术操作考核评分标准/r/n………………/r/n23/r/n第二十二项皮下注射技术操作考核评分标准/r/n………………/r/n24/r/n第二十三项物理降温技术操作考核评分标准/r/n………………/r/n25/r/n第二十四项心肺复苏技术操作考核评分标准/r/n………………/r/n26/r/n第二十五项经鼻/口腔吸痰法技术操作考核评分标准/r/n……/r/n27/r/n第二十六项气管切开〔呼吸机病人吸痰技术操作考核评分标准/r/n………/r/n28/r/n第二十七项心电监测技术操作考核评分标准/r/n………………/r/n29/r/n第二十八项血氧饱和度监测技术操作考核评分标准/r/n………/r/n30/r/n第二十九项输液泵／微量输注泵的使用技术考核评分标准/r/n………………/r/n31/r/n第三十项轴线翻身法技术操作考核评分标准/r/n……………/r/n32/r/n第三十一项〔一协助患者移向床头法技术操作考核评分标准/r/n…………/r/n33/r/n第三十一项〔二协助患者由床上移至平车技术操作考核评分标准/r/n………/r/n34/r/n第三十二项病人保护性约束技术操作考核评分标准/r/n…………/r/n35/r/n第三十三项痰标本采集法技术考核评分标准/r/n…………………/r/n36/r/n第三十四项咽拭子标本采集法技术操作考核评分标准/r/n………/r/n37/r/n第三十五项洗胃技术操作考核评分标准/r/n………/r/n38/r/n第三十六项"T"管引流护理技术操作考核评分标准/r/n……………/r/n39/r/n第三十七项造口护理技术操作考核评分标准/r/n…………………/r/n40/r/n第三十八项膀胱冲洗护理技术操作考核评分标准/r/n……………/r/n41/r/n第三十九项脑室引流的护理技术操作考核评分标准/r/n…………/r/n42/r/n第四十项胸腔闭式引流的护理技术操作考核评分标准/r/n……/r/n43/r/n第四十一项产时会阴消毒技术操作考核评分标准/r/n……………/r/n44/r/n第四十二项早产儿暖箱的应用技术操作考核评分标准/r/n………/r/n45/r/n第四十三项光照疗法技术操作考核评分标准/r/n…………………/r/n46/r/n第四十四项新生儿脐部护理技术操作考核评分标准/r/n…………/r/n47/r/n第四十五项听诊胎心音技术操作考核评分标准/r/n………………/r/n48/r/n第四十六项病人出入院操作考核评分标准/r/n……/r/n49/r/n第四十七项患者跌倒的预防技术操作考核评分标准/r/n…………/r/n50/r/n第四十八项压疮的预防及护理技术操作考核评分标准/r/n………/r/n51/r/n第四十八项中心吸痰法考核评分标准/r/n…………/r/n52/r/n一般洗手操作考核评分标准/r/n项目/r/n总/r/n分/r/n评分细则/r/n评分等级/r/nA/r/nB/r/nC/r/nD/r/n仪表/r/n5/r/n仪表端庄,服装整洁；/r/n5/r/n4/r/n3/r/n2/r/n评估/r/n10/r/n10/r/n8/r/n6/r/n4/r/n操作前准备/r/n5/r/n环境清洁；/r/n无长指甲。/r/n1/r/n2/r/n2/r/n0/r/n1/r/n1/r/n0/r/n1/r/n1/r/n0/r/n0/r/n0/r/n操作过程/r/n方法正确/r/n70分/r/n1.掌心相对,手指并拢,相互揉搓/r/n2.手心对手背沿指缝相互揉搓/r/n3.掌心相对,双手交叉指缝相互揉搓/r/n4.将五个手指尖并拢放在另一个手掌心旋转揉搓,交换进行/r/n5.右手握住左手大拇指旋转揉搓,交换进行/r/n6.弯曲手指使关节在另一个手掌心旋转揉搓,交换进行/r/n将五个手指尖并拢放在另一个手掌心旋转揉搓,交换进行/r/n7.流动水下彻底冲洗/r/n8.擦干双手〔用一次性纸巾/毛巾彻底擦干用干手机干燥双手/r/n9．关闭水龙头采用防止手部再污染的方法。/r/n10/r/n10/r/n10/r/n10/r/n10/r/n10/r/n3/r/n2/r/n5/r/n8/r/n8/r/n8/r/n8/r/n8/r/n8/r/n2/r/n1/r/n4/r/n6/r/n6/r/n6/r/n6/r/n6/r/n6/r/n1/r/n0/r/n3/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n0/r/n0/r/n2/r/n评价/r/n5分/r/n无污染、完成时间2分钟；/r/n5/r/n4/r/n3/r/n2/r/n提问/r/n5分/r/n5/r/n4/r/n3/r/n2/r/n总分/r/n100/r/n提问：1、说明一般洗手具体指征。〔2.5分/r/n回答一般洗手的注意事项。〔2.5分/r/n第二项无菌技术操作考核评分标准/r/n项目/r/n总/r/n分/r/n评分细则/r/n评分等级/r/n仪表/r/n5/r/n仪表端庄,服装整洁。/r/n5/r/n4/r/n3/r/n2/r/n评估/r/n4/r/n具有无菌操作环境和符合无菌标准物品。/r/n4/r/n3/r/n2/r/n1/r/n操作前准备/r/n5/r/n洗手,戴口罩。/r/n环境清洁,修剪指甲;/r/n备齐用物、并按节力及无菌操作要求放置用物。/r/n2/r/n2/r/n1/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n操/r/n作/r/n过/r/n程/r/n无菌钳使用/r/n18/r/n1．拿持物钳〔镊方法正确,用物符合无菌标准；/r/n2．注明、注意启用时间；/r/n6/r/n6/r/n6/r/n4/r/n4/r/n4/r/n2/r/n2/r/n2/r/n0/r/n0/r/n0/r/n无菌包使用/r/n12/r/n1.包皮、无菌物品消毒时间符合要求；/r/n5.注明开包时间〔夏、冬季标准。/r/n2/r/n2/r/n3/r/n3/r/n2/r/n1/r/n1/r/n2/r/n2/r/n1/r/n0/r/n0/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n无菌容器使用/r/n12/r/n1.容器开盖方法正确、无污染；/r/n2/r/n3/r/n3/r/n2/r/n2/r/n1/r/n2/r/n2/r/n1/r/n1/r/n0/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n无菌溶液使用/r/n10/r/n2.开瓶盖方法正确,不污染；/r/n3.倒液方法正确,不污染；/r/n4.盖瓶口方法正确,不污染,标注开瓶时间。/r/n3/r/n2/r/n3/r/n2/r/n2/r/n1/r/n2/r/n1/r/n1/r/n0/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n铺无菌盘/r/n12/r/n2/r/n3/r/n2/r/n3/r/n2/r/n1/r/n2/r/n1/r/n2/r/n1/r/n0/r/n1/r/n0/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n无菌手套/r/n使用法/r/n12/r/n3/r/n3/r/n6/r/n2/r/n2/r/n5/r/n1/r/n1/r/n4/r/n0/r/n0/r/n3/r/n评价/r/n5/r/n动作准确、熟练、节力；/r/n操作过程无污染。/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n提问/r/n5/r/n5/r/n4/r/n3/r/n2/r/n总分/r/n100/r/n提问：1.使用无菌持物钳的注意事项是哪些内容?〔2.5分；2.戴无菌手套的目的是什么?〔2.5分/r/n生命体征监测技术操作考核评分标准/r/n项目/r/n总分/r/n评分细则/r/n评分等级/r/n仪表/r/n5/r/n仪表端庄,服装整洁/r/n5/r/n4/r/n3/r/n2/r/n20/r/n评估患者生命体征情况,〔每项5分,共4项/r/n指导患者,并得到配合/r/n20/r/n10/r/n5/r/n2/r/n操作前准备/r/n5/r/n洗手,戴口罩/r/n2/r/n1/r/n0/r/n0/r/n备齐用物,放置合理/r/n3/r/n2/r/n1/r/n0/r/n体温的测量/r/n15/r/n测量前后核对方法正确,核对内容完整/r/n4/r/n1/r/n2/r/n1/r/n患者体位摆放正确/r/n3/r/n2/r/n1/r/n0/r/n操作程序正确/r/n4/r/n3/r/n2/r/n1/r/n测量结果正确/r/n4/r/n3/r/n2/r/n1/r/n脉搏的测量/r/n15/r/n核对正确/r/n2/r/n1/r/n0/r/n0/r/n患者体位摆放正确/r/n3/r/n2/r/n1/r/n0/r/n操作程序正确/r/n5/r/n4/r/n3/r/n2/r/n测量结果正确/r/n5/r/n4/r/n3/r/n2/r/n呼吸的测量/r/n15/r/n正确评估病人,分散病人注意力/r/n2/r/n1/r/n0/r/n0/r/n患者体位摆放正确/r/n3/r/n2/r/n1/r/n0/r/n操作程序正确/r/n5/r/n4/r/n3/r/n2/r/n测量结果正确/r/n5/r/n4/r/n3/r/n2/r/n血压的测量/r/n15/r/n测量前后核对方法正确,核对内容完整/r/n4/r/n3/r/n2/r/n1/r/n患者体位摆放正确/r/n3/r/n2/r/n1/r/n0/r/n操作程序正确/r/n4/r/n3/r/n2/r/n1/r/n测量结果正确/r/n4/r/n3/r/n2/r/n1/r/n操作后/r/n5/r/n正确处理用物和病人床单/r/n3/r/n2/r/n1/r/n0/r/n操作后记录签字、有异常情况及时通知医师/r/n2/r/n1/r/n0/r/n0/r/n提问/r/n5/r/n5/r/n4/r/n3/r/n2/r/n合计/r/n100/r/n提问：1.测体温注意事项。〔2.5分/r/n2.测血压的注意事项。〔2.5分/r/n口腔护理技术操作考核评分标准/r/n项目/r/n总分/r/n评分细则/r/n评分等级/r/n仪表/r/n5/r/n仪表端庄,服装整洁。/r/n5/r/n4/r/n3/r/n2/r/n评估与指导/r/n10/r/n1．询问、了解患者身体状况,口腔状况。/r/n2．解释、指导,取得患者的配合。/r/n5/r/n5/r/n4/r/n4/r/n3/r/n3/r/n2/r/n2/r/n操作前准备/r/n10/r/n1.洗手、戴口罩；/r/n2.根据病情需要准备药液及用物；/r/n3./r/n备齐用物,放置合理。/r/n2/r/n6/r/n2/r/n1/r/n5/r/n1/r/n0/r/n4/r/n0/r/n0/r/n3/r/n0/r/n操/r/n作/r/n过/r/n程/r/n安全与舒适/r/n10/r/n1.病人接受操作的环境舒适/r/n2.病人体位舒适〔侧卧或头偏向一侧/r/n3.假牙处理/r/n4.使用棉球数量清点/r/n2/r/n3/r/n3/r/n2/r/n1/r/n2/r/n2/r/n1.5/r/n0/r/n1/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n操/r/n作/r/n中/r/n50/r/n1.擦口唇、漱口;/r/n2.颌下铺巾、放置弯盘位置适当；/r/n3.正确使用压舌板、开口器等；/r/n4.夹取棉球或纱布方法正确；/r/n5.棉球湿度适宜；/r/n6.擦洗顺序、方法正确；/r/n7.口腔疾患处理正确；/r/n8.擦洗过程随时询问病人的感受；/r/n9.帮助病人擦净面部；/r/n10.操作中不污染床单及病人衣服。/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n操作后/r/n5/r/n使用后物品整理；/r/n指导患者正确的漱口方法及意义。/r/n2/r/n3/r/n1/r/n2/r/n0/r/n1/r/n0/r/n0/r/n评价/r/n5/r/n严格执行查对制度；/r/n操作中了解患者感受、沟通能力；/r/n区分清洁、干净,无交叉污染；/r/n2/r/n2/r/n1/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n提问/r/n5/r/n口腔护理的注意事项。/r/n5/r/n4/r/n3/r/n2/r/n总分/r/n100/r/n第五项鼻饲技术操作考核评分标准/r/n项目/r/n总分/r/n评分细则/r/n评分等级/r/nA/r/nB/r/nC/r/nD/r/n仪表/r/n5/r/n仪表端庄,服装整洁。/r/n5/r/n4/r/n3/r/n2/r/n评估与指导/r/n10/r/n倾听病人的需要和反应；/r/n2．解释、指导,取得患者的配合。/r/n5/r/n5/r/n4/r/n4/r/n3/r/n3/r/n2/r/n2/r/n操作前准备/r/n5/r/n备齐用物,放置合理；/r/n洗手,戴口罩。/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n操/r/n作/r/n过/r/n程/r/n安全与/r/n舒适/r/n10/r/n环境安静、清洁；/r/n病人体位舒适,让病人放松、配合；/r/n核查有无不安全隐患。〔查对、插管、喂食全过程/r/n2/r/n3/r/n5/r/n1/r/n2/r/n4/r/n0/r/n1/r/n3/r/n0/r/n0/r/n2/r/n插/r/n胃/r/n管/r/n30/r/n颌下铺巾；/r/n清洁并检查鼻腔；/r/n滑润导管并检查是否通畅；/r/n判断胃管的位置方法正确；/r/n胃管固定牢固、美观。/r/n2/r/n2/r/n2/r/n10/r/n7/r/n5/r/n2/r/n1/r/n1/r/n1/r/n8/r/n5/r/n4/r/n1/r/n0/r/n0/r/n0/r/n6/r/n3/r/n3/r/n0/r/n0/r/n0/r/n0/r/n4/r/n2/r/n2/r/n0/r/n鼻/r/n饲/r/n26/r/n1．喂食步骤正确、速度适宜；〔先抽试,再冲水、灌食/r/n2．食量、温度适宜；/r/n4．完毕用适量温水冲洗、清洁管腔；/r/n5．正确处理管端〔管子末端反折,纱布包好夹紧。/r/n10/r/n5/r/n3/r/n4/r/n4/r/n8/r/n5/r/n2/r/n3/r/n3/r/n6/r/n3/r/n1/r/n2/r/n2/r/n4/r/n2/r/n0/r/n1/r/n1/r/n操作后/r/n4/r/n妥善安置病人、整理床单位；/r/n用物处理正确并记录。/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n评价/r/n5/r/n病人舒适,无不良反应；/r/n步骤正确,洁、污分开。/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n提问/r/n5/r/n5/r/n4/r/n3/r/n2/r/n总分/r/n100/r/n提问：1.鼻饲的注意事项有哪些？〔2.5分2.回答确定胃管在胃内的方法。〔2.5分/r/n第六项女病人导尿技术操作考核评分标准/r/n项目/r/n总分/r/n评分细则/r/n评分等级/r/nA/r/nB/r/nC/r/nD/r/n仪表/r/n5/r/n仪表端庄,服装整洁,/r/n5/r/n4/r/n3/r/n2/r/n评估与指导/r/n10/r/n1.了解病情、膀胱充盈度、会阴部皮肤、粘膜情况；/r/n2.了解病人自理、合作程度、耐受力及心理反应；/r/n3.告知导尿目的、方法,语言规范；/r/n4.结合病人实际需要给予指导。/r/n2/r/n2/r/n3/r/n3/r/n1/r/n1/r/n2/r/n2/r/n0/r/n0/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n操作前准备/r/n4/r/n1.洗手,戴口罩；/r/n2./r/n备齐用物,放置合理；/r/n3.指导放松,在插管过程中协调配合。/r/n1/r/n1/r/n2/r/n1/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n操/r/n作/r/n过/r/n程/r/n安全与/r/n舒适/r/n10/r/n1.环境安静、清洁；〔关门窗、围屏风/r/n2/r/n4/r/n4/r/n1/r/n3/r/n3/r/n0/r/n2/r/n2/r/n0/r/n1/r/n1/r/n导/r/n尿/r/n56/r/n1.术者体位正确,符合力学原理；/r/n2.核对后臀下铺巾是否固定；〔垫/r/n3.协助病人清洁会阴方法正确并初步消毒,再次清洁双手；/r/n4.打开导尿包不污染,放置合理/r/n5.使用无菌钳,物品不污染/r/n6.戴无菌手套方法正确,不污染/r/n7.铺孔巾方法正确,不污染/r/n8.滑润导尿管不污染/r/n9.消毒阴唇、尿道口方法正确〔一手分开固定一手消毒；/r/n10.更换血管钳后插管方法正确/r/n11.观察插管深度、尿液及引流情况/r/n12.拔管方法正确并擦净外阴。/r/n2/r/n1/r/n5/r/n3/r/n4/r/n4/r/n6/r/n6/r/n10/r/n8/r/n5/r/n2/r/n1/r/n0/r/n4/r/n2/r/n3/r/n3/r/n5/r/n5/r/n8/r/n6/r/n4/r/n1/r/n0/r/n0/r/n3/r/n1/r/n2/r/n2/r/n4/r/n4/r/n6/r/n4/r/n3/r/n0/r/n0/r/n0/r/n2/r/n0/r/n1/r/n1/r/n3/r/n3/r/n4/r/n2/r/n2/r/n0/r/n操作后/r/n5/r/n2.用物处理恰当,洗手后记录并执行签字/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n评价/r/n5/r/n1.严格执行查对制度；3.隐私保护;/r/n2..严格遵守无菌技术；4.关爱病人。/r/n2/r/n3/r/n1/r/n2/r/n0/r/n0/r/n0/r/n0/r/n提问/r/n5/r/n5/r/n4/r/n3/r/n2/r/n总分/r/n100/r/n提问：1．回答导尿的目的。〔2.5分2.导尿时如何评估患者？〔2.5分/r/n第七项胃肠减压技术操作考核评分标准/r/n项目/r/n总分/r/n评分细则/r/n评分等级/r/nA/r/nB/r/nC/r/nD/r/n仪表/r/n5/r/n仪表端庄,服装整洁,面带微笑,语言柔和恰当/r/n5/r/n4/r/n3/r/n2/r/n评估与指导/r/n10/r/n核对确认患者,自我介绍/r/n了解病情、意识状态、鼻腔、腹部情况/r/n解释操作方法、目的、判断合作程度；/r/n结合病人实际给予指导；/r/n2/r/n3/r/n3/r/n2/r/n1/r/n2/r/n2/r/n1/r/n0/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n操作前准备/r/n5/r/n洗手、戴口罩；/r/n物品完好齐全,放置合理;/r/n指导患者放松,在插管过程中协调配合。/r/n2/r/n2/r/n1/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n操/r/n作/r/n过/r/n程/r/n安全与舒适/r/n10/r/n接受操作的环境舒适；/r/n体位舒适/r/n注意心理反应。/r/n3/r/n3/r/n4/r/n2/r/n2/r/n3/r/n1/r/n1/r/n2/r/n0/r/n0/r/n1/r/n胃/r/n肠/r/n减/r/n压/r/n45/r/n核对医嘱、清洁鼻腔、评估鼻腔情况；/r/n颌下铺巾、放置弯盘位置适当；/r/n检查胃管是否通畅、标记长度、润滑胃管；/r/n插胃管方法正确；/r/n插管过程随时观察病人的反应；/r/n胃管插入长度合适；/r/n检查胃管在胃内方法正确；/r/n接胃肠减压器正确、观察记录引流量；/r/n胃管固定牢固,美观；/r/n帮助病人擦净面部；/r/n操作中不污染床单及病人衣服。/r/n3/r/n3/r/n6/r/n6/r/n4/r/n5/r/n5/r/n4/r/n4/r/n2/r/n3/r/n2/r/n2/r/n5/r/n5/r/n3/r/n4/r/n4/r/n3/r/n3/r/n1/r/n2/r/n1/r/n1/r/n4/r/n4/r/n2/r/n3/r/n3/r/n2/r/n2/r/n1/r/n1/r/n1/r/n0/r/n3/r/n3/r/n1/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n停胃肠/r/n减压/r/n5/r/n核对医嘱、拔管方法正确；/r/n帮助病人清洁面部。/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n操作后/r/n5/r/n妥善安置病人/r/n正确处理用物和床单元并作好记录/r/n2/r/n3/r/n1/r/n2/r/n0/r/n1/r/n0/r/n0/r/n评价/r/n10/r/n严格执行查对制度；/r/n操作正确,动作轻柔；/r/n胃肠减压有效。/r/n3/r/n3/r/n4/r/n2/r/n2/r/n3/r/n1/r/n1/r/n2/r/n0/r/n0/r/n1/r/n提问/r/n5/r/n5/r/n4/r/n3/r/n2/r/n总分/r/n100/r/n提问：1．胃肠减压的目的是什么？〔2.5分2．胃肠减压的注意事项有哪些？〔2.5分/r/n第八项大量不保留灌肠技术操作考核评分标准/r/n科室：姓名：得分：/r/n项目/r/n总分/r/n评分细则/r/n评分等级/r/n仪表/r/n5/r/n仪表端庄,服装整洁。/r/n5/r/n4/r/n3/r/n2/r/n评估与指导/r/n10/r/n了解病情及肛门部皮肤粘膜状况；/r/n3/r/n3/r/n4/r/n2/r/n2/r/n3/r/n1/r/n1/r/n2/r/n0/r/n0/r/n1/r/n操作前准备/r/n6/r/n备齐用物,顺序放置,洗手,戴口罩；/r/n灌肠液配制正确〔浓度、量、温度。/r/n2/r/n4/r/n1/r/n3/r/n0/r/n2/r/n0/r/n1/r/n操/r/n作/r/n过/r/n程/r/n安全与/r/n舒适/r/n10/r/n环境安静、清洁〔关门窗、围屏风；/r/n认真核对医嘱,保护病人隐私；/r/n病人体位正确、舒适,注意保暖。/r/n3/r/n3/r/n4/r/n2/r/n2/r/n3/r/n1/r/n1/r/n2/r/n0/r/n0/r/n1/r/n灌/r/n肠/r/n54/r/n再次核对后,臀下铺巾或清洁油布；/r/n灌肠筒高度适宜〔40/r/n—60cm/r/n；/r/n肛管润滑充分；/r/nD/r/n4/r/n6/r/n2/r/n4/r/n6/r/n6/r/n2/r/n5/r/n5/r/n6/r/n4/r/n4/r/n3/r/n5/r/n1/r/n3/r/n5/r/n5/r/n1/r/n4/r/n4/r/n5/r/n3/r/n3/r/n2/r/n4/r/n0/r/n2/r/n4/r/n4/r/n0/r/n3/r/n3/r/n4/r/n2/r/n2/r/n1/r/n3/r/n0/r/n1/r/n3/r/n3/r/n0/r/n2/r/n2/r/n3/r/n1/r/n1/r/n操作后/r/n5/r/n妥善安置病人及床单位；/r/n使用后用物处理正确；洗手后正确记录/r/n2/r/n3/r/n1/r/n2/r/n0/r/n1/r/n0/r/n0/r/n评价/r/n5/r/n动作轻巧、准确。/r/n5/r/n4/r/n3/r/n2/r/n提问/r/n5/r/n灌肠的目的及注意事项/r/n5/r/n4/r/n3/r/n2/r/n总分/r/n100/r/n第九项鼻塞〔鼻导管吸氧技术操作考核评分标准/r/n项目/r/n总分/r/n评分细则/r/n评分等级/r/n仪表/r/n5/r/n仪表端庄,服装整洁。/r/n5/r/n4/r/n3/r/n2/r/n评估与指导/r/n10/r/n了解病情、意识及缺氧程度,鼻腔内状况；/r/n观察病人合作程度及心理反应；/r/n解释吸氧目的、配合方法；/r/n结合病人实际情况给予指导；/r/n3/r/n2/r/n2/r/n3/r/n2/r/n1/r/n1/r/n2/r/n1/r/n0/r/n0/r/n1/r/n0/r/n0/r/n0/r/n0/r/n操作前准备/r/n10/r/n洗手,戴口罩。/r/n5/r/n5/r/n4/r/n4/r/n3/r/n3/r/n2/r/n2/r/n操/r/n作/r/n过/r/n程/r/n安全与/r/n舒适/r/n10/r/n检查用氧安全〔漏气、明火、有污染；/r/n病人体位舒适,环境清洁,告知四防。/r/n6/r/n4/r/n5/r/n3/r/n4/r/n2/r/n3/r/n1/r/n吸/r/n氧/r/n30/r/n检查、清洁鼻腔,连接鼻塞〔鼻导管并试通畅；/r/n按需要正确调节氧气流量；/r/n插鼻塞〔鼻导管方法正确；/r/n鼻塞〔鼻导管插入深度合适；/r/n导管固定牢固,美观；/r/n记录用氧时间；/r/n操作步骤正确〔包括打开开关时操作顺序。/r/n5/r/n4/r/n5/r/n5/r/n4/r/n2/r/n5/r/n4/r/n3/r/n4/r/n4/r/n3/r/n1/r/n4/r/n3/r/n2/r/n3/r/n3/r/n2/r/n0/r/n3/r/n2/r/n1/r/n2/r/n2/r/n1/r/n0/r/n2/r/n停/r/n止/r/n吸/r/n氧/r/n20/r/n取下鼻塞〔鼻导管方法正确；/r/n关闭氧气顺序正确；/r/n帮助病人清洁面部；/r/n记录停氧时间；/r/n操作步骤正确〔先拨管后关氧气表。/r/n4/r/n5/r/n3/r/n2/r/n6/r/n3/r/n4/r/n2/r/n1/r/n5/r/n2/r/n3/r/n1/r/n0/r/n4/r/n1/r/n2/r/n0/r/n0/r/n3/r/n操作后/r/n4/r/n1.妥善安置病人和整理用物,洗手并作好护理记录；/r/n2./r/n3.告知患者如感到鼻咽部干燥不适或者胸闷憋气时,应当及时通知医护人员；/r/n4.告知患者有关用氧安全的知识。/r/n1/r/n1/r/n1/r/n1/r/n1/r/n1/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n评价/r/n5/r/n动作熟练、步骤正确；/r/n严格执行查对制度、遵守无菌技术。/r/n2/r/n3/r/n1/r/n2/r/n0/r/n1/r/n0/r/n0/r/n提问/r/n5/r/n5/r/n4/r/n3/r/n2/r/n总分/r/n100/r/n提问：1．鼻导管给氧氧浓度的计算方法〔2.5分；2.为患者吸氧时的注意事项〔2.5分。/r/n换药技术操作考核评分标准/r/n项目/r/n总分/r/n评分细则/r/n评分等级/r/nA/r/nB/r/nC/r/nD/r/n仪表/r/n5/r/n服装整洁、仪表端庄。/r/n5/r/n4/r/n3/r/n2/r/n评估与指导/r/n10/r/n1．了解病人身体状况及观察伤口局部情况；/r/n2．确定病人的合作能力；/r/n3．/r/n解释、指导,取得配合。/r/n3/r/n3/r/n4/r/n2/r/n2/r/n3/r/n1/r/n1/r/n2/r/n0/r/n0/r/n1/r/n操作前准备/r/n6/r/n1．准备治疗车,洗手,戴口罩；/r/n2．备齐用物,放置合理。/r/n3/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n操/r/n作/r/n过/r/n程/r/n安全与/r/n舒适/r/n9/r/n环境安静、清洁、舒适；/r/n核对医嘱,再次观察病人伤口；/r/n病人体位正确、舒适,注意保暖。/r/n3/r/n3/r/n3/r/n2/r/n2/r/n2/r/n1/r/n1/r/n1/r/n0/r/n0/r/n0/r/n操/r/n作/r/n中/r/n45/r/n治疗车推至床旁,做好解释工作；/r/n再次核对,正确暴露伤口；/r/n区分伤口类型,并采取相应的换药方法；/r/n取伤口敷料方法正确；/r/n消毒伤口方法正确；/r/n使用镊子方法正确；/r/n清洗伤口方法正确；/r/n固定纱布方法正确。/r/n5/r/n5/r/n6/r/n5/r/n6/r/n6/r/n6/r/n6/r/n5/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n3/r/n3/r/n2/r/n3/r/n2/r/n2/r/n2/r/n2/r/n3/r/n2/r/n2/r/n0/r/n2/r/n0/r/n0/r/n0/r/n0/r/n2/r/n操作后/r/n13/r/n妥善安置病人；/r/n告知病人换药后注意事项；/r/n用物处理正确；/r/n洗手,记录观察情况,执行签字。/r/n3/r/n4/r/n3/r/n3/r/n2/r/n3/r/n2/r/n2/r/n1/r/n2/r/n1/r/n1/r/n0/r/n1/r/n0/r/n0/r/n评价/r/n7/r/n操作动作轻柔、准确,伤口清洁,敷料平整；/r/n操作符合换药基本原则、程序,病人无不适。/r/n4/r/n3/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n提问/r/n5/r/n5/r/n4/r/n3/r/n2/r/n总分/r/n100/r/n提问：1．/r/n换药目的是什么/r/n?〔2分/r/n2．/r/n换药注意事项是什么/r/n?〔3分/r/n第十一项雾化吸入技术操作考核评分标准/r/n项目/r/n总分/r/n评分细则/r/n评分等级/r/nA/r/nB/r/nC/r/nD/r/n仪表/r/n5/r/n仪表端庄,服装整洁。/r/n5/r/n4/r/n3/r/n2/r/n评估与指导/r/n5/r/n1．评估患者病情及合作程度；/r/n2．解释、指导,取得患者的配合。/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n操作前准备/r/n5/r/n洗手,戴口罩；/r/n检查仪器、备齐用物,放置合理。/r/n2/r/n3/r/n1/r/n2/r/n0/r/n1/r/n0/r/n0/r/n操/r/n作/r/n过/r/n程/r/n70/r/n1．核对正确/r/n2．正确配置药物/r/n3．患者体位摆放正确/r/n4．操作程序正确/r/n5．水槽内有足够的冷水/r/n6．雾化操作方法正确/r/n7．雾化时间正确/r/n8．注意观察患者病情变化,并及时告知医师/r/n9/r/n9/r/n9/r/n9/r/n9/r/n9/r/n7/r/n9/r/n7/r/n7/r/n7/r/n7/r/n7/r/n7/r/n5/r/n7/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n3/r/n5/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n1/r/n3/r/n操作后/r/n5/r/n处理用物方法正确/r/n操作结束洗手、签字/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n评价/r/n5/r/n操作顺序正确、熟练/r/n正确指导患者雾化吸入和排痰/r/n2/r/n3/r/n1/r/n2/r/n0/r/n1/r/n0/r/n0/r/n提问/r/n5/r/n5/r/n4/r/n3/r/n2/r/n总分/r/n100/r/n提问：1．雾化吸入的目的是什么?〔2.5分/r/n2．如何指导患者进行正确的雾化吸入?〔2.5分/r/n第十二项血糖监测技术操作考核评分标准/r/n项目/r/n总/r/n分/r/n评分细则/r/n评分等级/r/nA/r/nB/r/nC/r/nD/r/n仪表/r/n5/r/n仪表、语言、举止符合专业规范/r/n5/r/n4/r/n3/r/n2/r/n评估与指导/r/n10/r/n1．询问、了解患者身体状况；/r/n2．向病人解释血糖监测的目的、事项；/r/n3．指导,取得配合。/r/n5/r/n3/r/n2/r/n4/r/n2/r/n1/r/n3/r/n1/r/n0/r/n2/r/n0/r/n0/r/n操作前准备/r/n10/r/n1．洗手、戴口罩；/r/n2．备齐用物,正确安装采血笔,/r/n调节好采血笔穿刺深度。/r/n5/r/n5/r/n4/r/n4/r/n3/r/n3/r/n2/r/n2/r/n操/r/n作/r/n过/r/n程/r/n安全与/r/n舒适/r/n10/r/n体位舒适、环境清洁；/r/n用物放置于床旁桌或护理车上；/r/n核对血糖仪上的号码与试纸号码是否一致。/r/n2/r/n2/r/n6/r/n1/r/n1/r/n4/r/n0/r/n0/r/n2/r/n0/r/n0/r/n0/r/n操/r/n作/r/n中/r/n45/r/n1．核对；/r/n2．做好准备；/r/n3．按照无菌技术原则采血；/r/n4．滴血量准确,无试纸污染现象；/r/n5．读数、准确记录,血糖异常时通知医生；/r/n6．指导病人穿刺后按压1-2分钟；/r/n7．指导长期监测血糖的患者掌握血糖监测的方法。/r/n5/r/n6/r/n10/r/n6/r/n6/r/n6/r/n6/r/n4/r/n4/r/n8/r/n4/r/n4/r/n4/r/n4/r/n3/r/n2/r/n6/r/n2/r/n2/r/n2/r/n2/r/n2/r/n0/r/n4/r/n0/r/n0/r/n0/r/n0/r/n操作后/r/n5/r/n协助恢复舒适体位、整理床单元；/r/n正确处理使用后的物品。/r/n2/r/n3/r/n1/r/n2/r/n0/r/n1/r/n0/r/n0/r/n评价/r/n10/r/n严格核对与无菌技术、进针深度准确；/r/n动作轻柔、稳重、准确。/r/n5/r/n5/r/n4/r/n4/r/n3/r/n3/r/n1/r/n1/r/n提问/r/n5/r/n5/r/n4/r/n3/r/n2/r/n总分/r/n100/r/n提问：1.血糖监测的目的是什么？〔2分/r/n2.正确回答血糖监测的注意事项有哪些内容？〔3分/r/n第十三项口服给药技术操作考核评分标准/r/n项目/r/n总分/r/n评分细则/r/n评分等级/r/nA/r/nB/r/nC/r/nD/r/n仪表/r/n5/r/n仪表端庄,服装整洁。/r/n5/r/n4/r/n3/r/n2/r/n评估与指导/r/n10/r/n1．询问、了解患者药物过敏史、身体状,观察患者口咽部是否有溃疡、糜烂等情况。/r/n2．解释、指导,取得患者配合。/r/n5/r/n5/r/n4/r/n4/r/n3/r/n3/r/n2/r/n2/r/n操作前准备/r/n10/r/n1./r/n洗手、戴口罩/r/n2./r/n根据病情需要准备药物及用物/r/n3.核对医嘱及服药本小药卡./r/n2/r/n6/r/n2/r/n1/r/n4/r/n1/r/n0/r/n2/r/n0/r/n0/r/n0/r/n0/r/n操/r/n作/r/n过/r/n程/r/n安全与/r/n舒适/r/n10/r/n1/r/n.摆药区安静整洁,药品放置合理./r/n2/r/n./r/n病人服药体位舒适安全。〔如昏迷及精神异常等病人/r/n3.患者掌握特殊药物服用方法及注意要点。/r/n2/r/n4/r/n4/r/n1/r/n3/r/n3/r/n0/r/n2/r/n2/r/n0/r/n1/r/n1/r/n操/r/n作/r/n中/r/n50/r/n1.取药前检查药物标签、有效期。/r/n2./r/n./r/n取片剂剂量、方法正确。/r/n3.准备粉剂剂量、方法正确./r/n4.取水剂剂量、方法正确。/r/n5.取油剂剂量、方法正确./r/n6.摆完后整理药柜及用物./r/n7/r/n./r/n重新核对,再两人查对。/r/n8/r/n./r/n发药前再次核对〔三查七对/r/n9/r/n./r/n协助服药的方法正确〔老人、小儿、病重者、鼻饲者、不能自理者/r/n10/r/n./r/n患者因故不能服药做好交接班。/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n操作后/r/n5/r/n1.观察患者服药后效果及不良反应./r/n2.收回药杯清洁消毒方法正确./r/n3.整理用物,清洁药盘。/r/n3/r/n1/r/n1/r/n2/r/n0/r/n0/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n评价/r/n5/r/n1.操作动作熟练、规范./r/n2.严格核对；/r/n3.严格执行查对制度。/r/n1/r/n2/r/n2/r/n0/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n提问/r/n5/r/n5/r/n4/r/n3/r/n2/r/n总分/r/n1/r/n0/r/n0/r/n提问：1、回答口服给药应给患者的指导内容。2、口服给药的注意事项/r/n第十四项密闭式输液技术操作考核评分标准/r/n项目/r/n总分/r/n评分细则/r/n评分等级/r/nA/r/nB/r/nC/r/nD/r/n仪表/r/n5/r/n仪表端庄,服装整洁。/r/n5/r/n4/r/n3/r/n2/r/n评估与指导/r/n10/r/n2/r/n2/r/n2/r/n2/r/n2/r/n1/r/n1/r/n1/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n操作前准备/r/n5/r/n洗手,戴口罩；/r/n备齐用物,放置合理。/r/n2/r/n3/r/n1/r/n2/r/n0/r/n1/r/n0/r/n0/r/n操/r/n作/r/n过/r/n程/r/n安全与/r/n舒适/r/n10/r/n5/r/n5/r/n4/r/n4/r/n3/r/n3/r/n2/r/n2/r/n准/r/n备/r/n药/r/n液/r/n16/r/n3/r/n4/r/n2/r/n5/r/n2/r/n2/r/n3/r/n1/r/n4/r/n1/r/n1/r/n2/r/n0/r/n3/r/n0/r/n0/r/n1/r/n0/r/n2/r/n0/r/n输/r/n液/r/n40/r/nD/r/n4/r/n4/r/n4/r/n3/r/n6/r/n3/r/n8/r/n4/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n4/r/n2/r/n6/r/n3/r/n1/r/n1/r/n1/r/n1/r/n1/r/n1/r/n2/r/n2/r/n4/r/n2/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n1/r/n2/r/n1/r/n0/r/n0/r/n操作后/r/n4/r/n安置病人,整理输液车和床单位；/r/n用物处理正确,洗手,执行签字。/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n评价/r/n5/r/n操作正确,动作轻柔,点滴通畅；/r/n严格遵守无菌技术；严格查对制度；/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n提问/r/n5/r/n5/r/n4/r/n3/r/n2/r/n总分/r/n100/r/n提问：1.为患者进行密闭式输液时应注意哪些问题?〔2.5分/r/n2.一般情况下如何为患者调节输液速度?〔2.5分/r/n第十五项密闭式静脉输血技术操作考核评分标准/r/n项目/r/n总分/r/n评分细则/r/n评分等级/r/nA/r/nB/r/nC/r/nd/r/n仪表/r/n5/r/n仪表端庄,服装整洁/r/n5/r/n4/r/n3/r/n2/r/n评估与指导/r/n10/r/n1．评估患者病情、输血史及合作程度及血管情况/r/n2．解释、指导,取得患者配合。/r/n5/r/n5/r/n4/r/n4/r/n3/r/n3/r/n2/r/n2/r/n操/r/n作/r/n前/r/n10/r/n1．洗手,戴口罩,备齐用物,放置合理；/r/n2．医嘱核对,血袋包装上7项和血袋完整情况、血液质量检查无误；/r/n3、输血前双人三查七对。/r/n2/r/n4/r/n4/r/n1/r/n3/r/n3/r/n0/r/n2/r/n2/r/n0/r/n1/r/n1/r/n操/r/n作/r/n中/r/n50/r/n1．输血前再次双人核对；/r/n2．患者体位摆放正确；/r/n3．操作顺序正确；/r/n4．按照无菌技术原则穿刺；/r/n5．合理调节输血速度；/r/n6．患者安全舒适；/r/n7．注意观察有无输血反应,并及时告知医师；/r/n8．输血后核对。/r/n5/r/n5/r/n5/r/n10/r/n10/r/n5/r/n5/r/n5/r/n4/r/n4/r/n4/r/n8/r/n8/r/n4/r/n4/r/n4/r/n3/r/n3/r/n3/r/n6/r/n6/r/n3/r/n3/r/n3/r/n2/r/n2/r/n2/r/n4/r/n4/r/n2/r/n2/r/n2/r/n操/r/n作/r/n后/r/n10/r/n1．处理用物方法正确；/r/n2．不良反应告知,输血袋用后低温保存24小时。/r/n3．操作结束洗手、记录；/r/n3/r/n5/r/n2/r/n2/r/n4/r/n1/r/n1/r/n3/r/n0/r/n0/r/n2/r/n0/r/n评价/r/n10/r/n操作熟练、无菌、按要求核对；/r/n5/r/n4/r/n3/r/n2/r/n5/r/n4/r/n3/r/n2/r/n提问/r/n5/r/n5/r/n4/r/n3/r/n2/r/n合计/r/n100/r/n提问：1.输血前应核对哪些项目？〔2.5分/r/n2．输血的注意事项有哪些,核对不能发出的血包括哪些?〔2.5分/r/n第十六项静脉留置针技术操作考核评分标准/r/n项目/r/n总分/r/n评分细则/r/n评分等级/r/nA/r/nB/r/nC/r/nD/r/n仪表/r/n5/r/n仪表端庄,服装整洁。/r/n5/r/n4/r/n3/r/n2/r/n评估与指导/r/n10/r/n1．观察患者病情变化、了解穿刺局部皮肤及血管情况；/r/n2．解释静脉留置针目的、方法、体位等,并结合情况予以指导。/r/n5/r/n5/r/n4/r/n4/r/n3/r/n3/r/n2/r/n2/r/n操作前准备/r/n5/r/n洗手、戴口罩；/r/n备齐用物,放置合理。/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n操/r/n作/r/n过/r/n程/r/n安全与/r/n舒适/r/n5/r/n为患者选择舒适的穿刺体位；/r/n核对医嘱、输液卡。/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n操/r/n作/r/n中/r/n50/r/n1．再次核对并向患者解释；/r/n2．消毒方法正确,选择血管恰当；/r/n3．使用静脉留置针芯方法正确、节力；/r/n4．抽出针芯方法正确；/r/n5．输液器与肝素帽连接正确；/r/n6．无菌透明膜固定牢固、舒适,注明穿刺日期和时间；/r/n7．调节滴速,再次核对；/r/n8．协助患者取舒适卧位,将呼叫器放置于患者可及处。/r/n5/r/n10/r/n10/r/n5/r/n5/r/n5/r/n5/r/n5/r/n4/r/n8/r/n8/r/n4/r/n4/r/n4/r/n3/r/n4/r/n3/r/n6/r/n6/r/n3/r/n3/r/n3/r/n2/r/n3/r/n2/r/n4/r/n4/r/n2/r/n2/r/n2/r/n1/r/n2/r/n操作后/r/n10/r/n1、整理用物,处理方法正确；/r/n2、洗手,记录执行情况；/r/n3、向患者讲解自我保护的基本知识〔不按揉、防进水。/r/n3/r/n3/r/n4/r/n2/r/n2/r/n3/r/n1/r/n1/r/n2/r/n0/r/n0/r/n1/r/n评价/r/n10/r/n1、患者穿刺局部无肿胀、渗漏；/r/n2、为患者提供必要的自我防护知识；/r/n3、操作中严格遵守无菌操作与核对。/r/n3/r/n3/r/n4/r/n2/r/n2/r/n3/r/n1/r/n1/r/n2/r/n0/r/n0/r/n1/r/n提问/r/n5/r/n5/r/n4/r/n3/r/n2/r/n总分/r/n100/r/n提问：1、患者行静脉留置针的目的是什么？/r/n2、给患者行静脉留置针的注意事项是什么？/r/n第十七项静脉采集血标本技术操作考核评分标准/r/n项目/r/n总分/r/n评分细则/r/n评分等级/r/nA/r/nB/r/nC/r/nD/r/n仪表/r/n5/r/n仪表端庄,服装整洁。/r/n5/r/n4/r/n3/r/n2/r/n评估与指导/r/n10/r/n了解病情,观察局部皮肤、血管状况；/r/n3/r/n3/r/n4/r/n2/r/n2/r/n3/r/n1/r/n1/r/n2/r/n0/r/n0/r/n1/r/n操作前准备/r/n5/r/n洗手,戴口罩；/r/n备齐用物〔标本容器,/r/n放置合理/r/n。/r/n2/r/n3/r/n1/r/n2/r/n0/r/n1/r/n0/r/n0/r/n操/r/n作/r/n过/r/n程/r/n安全与/r/n舒适/r/n5/r/n环境清洁、舒适,光线明亮；/r/n认真核对医嘱、检验单及病人；/r/n病人舒适,注意保暖。/r/n2/r/n2/r/n1/r/n1/r/n1/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n0/r/n采/r/n血/r/n60/r/n1．核对病人、检验项目、容器与标签；/r/n2．检查无菌物品的内容、方法正确；/r/n3．取用消毒剂、无菌物品不污染；/r/n4．用注射器、针头的方法正确,不污染；/r/n5．皮肤消毒方法正确；/r/n6．系止血带部位适宜；/r/n7．穿刺进针角度、深度适宜；/r/n8．穿刺一针见血〔退针一次扣2分；/r/n9．有回血后固定注射器、针头适宜；/r/n10．采血量正确；/r/n11．松止血带、拔针方法正确；/r/n12．指导病人按压穿刺部位；/r/n13．血标本注入标本瓶方法正确；/r/n14核对医嘱,执行签字。/r/n5/r/n5/r/n5/r/n5/r/n5/r/n3/r/n2/r/n5/r/n5/r/n5/r/n5/r/n3/r/n2/r/n5/r/n4/r/n4/r/n4/r/n4/r/n4/r/n2/r/n1/r/n4/r/n4/r/n4/r/n4/r/n2/r/n1/r/n4/r/n3/r/n3/r/n3/r/n3/r/n3/r/n1/r/n0/r/n3/r/n3/r/n3/r/n3/r/n1/r/n0/r/n3/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n2/r/n0/r/n2/r/n2/r/n操作后/r/n5/r/n助病人取舒适体位；/r/n物品用后处理正确并洗手。/r/n2/r/n3/r/n1/r/n2/r/n0/r/n1/r/n0/r/n0/r/n评价/r/n5/r/n操作熟练；/r/n遵守无菌技术与核对制度。/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n提问/r/n5/r/n5/r/n4/r/n3/r/n2/r/n总分/r/n100/r/n提问：1、采集血标本前后为患者做哪些指导？〔2.5分/r/n2、采集血标本的注意事项？〔2.5分/r/n第十八项静脉注射技术操作考核评分标准/r/n项目/r/n总分/r/n评分细则/r/n评分等级/r/nA/r/nB/r/nC/r/nD/r/n仪表/r/n5/r/n仪表端庄,服装整洁。/r/n5/r/n4/r/n3/r/n2/r/n评估与指导/r/n10/r/n了解身体状况及局部皮肤、血管状况；/r/n讲解目的、用药后可能的反映；/r/n解释操作方法及配合指导。/r/n4/r/n3/r/n3/r/n3/r/n2/r/n2/r/n2/r/n1/r/n1/r/n1/r/n0/r/n0/r/n操作前准备/r/n5/r/n洗手,戴口罩；/r/n备齐用物、放置合理。/r/n2/r/n3/r/n1/r/n2/r/n0/r/n0/r/n0/r/n0/r/n操/r/n作/r/n过/r/n程/r/n安全与/r/n舒适/r/n5/r/n核对医嘱、治疗卡；/r/n病人卧位正确、舒适、保暖。/r/n3/r/n2/r/n2/r/n1/r/n1/r/n1/r/n0/r/n0/r/n抽/r/n药/r/n25/r/n核查药液及无菌物品方法正确；/r/n消毒及无菌物品时方法正确,不污染；/r/n药瓶〔安瓿消毒时方法正确,不污染；/r/n取用注射器针头,不污染；/r/n抽药方式正确、剂量准确,不污染；/r/n抽药后放置无菌盘中,不污染。/r/n5/r/n3/r/n2/r/n5/r/n5/r/n5/r/n4/r/n2/r/n2/r/n4/r/n4/r/n4/r/n3/r/n1/r/n1/r/n3/r/n3/r/n3/r/n2/r/n0/r/n0/r/n2/r/n2/r/n2/r/n注/r/n射/r/n35/r/n再次核对病人及医嘱、选择穿刺静脉；/r/n消毒皮肤范围、方法正确；/r/n系止血带部位、方法正确；/r/n排气方法正确,无药液浪费和污染；/r/n穿刺一针见血〔退针一次扣2分；/r/n有回血后及时"二松"〔拳、止血带,固定针头；/r/n缓慢注射,并观察局部和全身情况；/r/n拔针、按压正确；/r/n核对医嘱,执行后签字。/r/n5/r/n5/r/n2/r/n3/r/n5/r/n5/r/n5/r/n2/r/n3/r/n4/r/n4/r/n1/r/n2/r/n4/r/n3/r/n4/r/n1/r/n2/r/n3/r/n3/r/n0/r/n1/r/n3/r/n3/r/n3/r/n0/r/n1/r/n2/r/n2/r/n0/r/n0/r/n2/r/n2/r/n2/r/n0/r/n0/r/n操作后/r/n5/r/n治疗车及物品用后处理正确,洗手；/r/n密切观察用药反应。/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n评价/r/n5/r/n操作规范、熟练；/r/n遵守无菌技术与核对制度。/r/n2/r/n3/r/n1/r/n2/r/n0/r/n1/r/n0/r/n0/r/n提问/r/n5/r/n5/r/n4/r/n3/r/n2/r/n总分/r/n100/r/n提问：1.静脉注射时评估患者其内容有哪些？〔2.5分/r/n2.给患者行静脉注射时对其指导内容有哪些？〔2.5分/r/n第十九项动脉血标本的采集技术操作考核评分标准/r/n项目/r/n总分/r/n评分细则/r/n评分等级/r/n得分及扣分依据/r/nA/r/nB/r/nC/r/nD/r/n仪表/r/n5/r/n仪表端庄,服装整洁。/r/n5/r/n4/r/n3/r/n2/r/n评估与指导/r/n10/r/n向病人解释操作方法、目的；/r/n了解患者身体状况及吸氧状况等；/r/n告知平静呼吸意义、穿刺点的按压及保护。/r/n4/r/n3/r/n3/r/n3/r/n2/r/n2/r/n2/r/n1/r/n1/r/n1/r/n0/r/n0/r/n操作前准备/r/n10/r/n洗手、戴口罩；/r/n备物完整并放置正确。/r/n5/r/n5/r/n4/r/n4/r/n3/r/n3/r/n2/r/n2/r/n操/r/n作/r/n过/r/n程/r/n安全与/r/n舒适/r/n10/r/n病人接受操作的环境舒适；/r/n病人体位舒适；/r/n帮助或指导患者按压穿刺部位。/r/n2/r/n4/r/n4/r/n1/r/n3/r/n3/r/n0/r/n2/r/n2/r/n0/r/n1/r/n1/r/n操/r/n作/r/n中/r/n45/r/n核对；选择动脉〔挠动脉、股动脉/r/n抽少量肝素〔0.5ml,湿润注射器后推掉余液。/r/n暴露穿刺部位,消毒穿刺部位皮肤及操作者左手食指；/r/n穿刺方法正确。/r/n采集的血标本量适中；/r/n指导患者正确放松和平静呼吸；/r/n拔针后针尖斜面隔绝空气方法正确；/r/n采集的血液与肝素混匀。/r/n采血过程随时询问病人的感受。/r/n5/r/n5/r/n6/r/n8/r/n5/r/n5/r/n5/r/n2/r/n4/r/n4/r/n4/r/n4/r/n6/r/n4/r/n4/r/n6/r/n1/r/n2/r/n3/r/n3/r/n2/r/n4/r/n3/r/n3/r/n4/r/n0/r/n1/r/n2/r/n2/r/n0/r/n2/r/n2/r/n2/r/n3/r/n0/r/n0/r/n操作后/r/n5/r/n整理用物；/r/n指导患者正确按压局部并保持穿刺部位清洁、干燥。/r/n2/r/n3/r/n1/r/n2/r/n0/r/n1/r/n0/r/n0/r/n评价/r/n10/r/n严格执行查对制度；/r/n严格执行无菌技术操作技术。/r/n操作流畅,效果好。/r/n4/r/n3/r/n3/r/n3/r/n2/r/n2/r/n2/r/n1/r/n1/r/n1/r/n0/r/n0/r/n提问/r/n5/r/n5/r/n4/r/n3/r/n2/r/n总分/r/n100/r/n提问：血标本的目的是什么？2、为患者采动脉血标本时要注意什么？/r/n第二十项肌内注射技术操作考核评分标准/r/n项目/r/n评分细则/r/n得分及/r/n扣分依据/r/n仪表/r/n评估与指导/r/n3/r/n3/r/n2/r/n2/r/n严格查对制度和无菌技术。/r/n操作流畅,效果好。/r/n5/r/n4/r/n3/r/n2/r/n提问：1.如何对肌肉注射患者进行指导？〔2.5分/r/n2.行肌肉注射的注意事项有哪些？〔2.5分。/r/n第二十一项皮内注射技术操作考核评分标准/r/n项目/r/n总分/r/n评分细则/r/n评分等级/r/n得分及/r/n扣分依据/r/n仪表/r/n5/r/n仪表端庄,服装整。/r/n5/r/n4/r/n3/r/n2/r/n评估与指导/r/n10/r/n了解病情,药物过敏史及局部皮肤状况；/r/n解释指导操作目的及配合、注意事项。/r/n5/r/n5/r/n4/r/n4/r/n3/r/n3/r/n2/r/n2/r/n操作前准备/r/n5/r/n洗手,戴口罩；/r/n备齐用物,放置合理。/r/n2/r/n3/r/n1/r/n2/r/n0/r/n1/r/n0/r/n0/r/n操/r/n作/r/n过/r/n程/r/n安全与/r/n舒适/r/n10/r/n认真核对医嘱、并详细询问过敏史；/r/n环境安静病人体位舒适/r/n8/r/n2/r/n6/r/n1/r/n4/r/n0/r/n2/r/n0/r/n抽/r/n吸/r/n药/r/n液/r/n20/r/n1．配制或检查药液及无菌物品正确；/r/n2．取用无菌镊方法正确,不污染；/r/n3．取用注射器、针头正确,不污染；/r/n4．抽吸药液方法正确；/r/n5．消毒药瓶、抽吸药液不污染,抽吸后放置正确。/r/n4/r/n4/r/n4/r/n4/r/n4/r/n3/r/n3/r/n3/r/n3/r/n3/r/n2/r/n2/r/n2/r/n2/r/n2/r/n1/r/n1/r/n1/r/n1/r/n1/r/n注/r/n射/r/n25/r/n1．选择注射部位正确；/r/n2．消毒方法正确；〔方法、范围、无菌/r/n3．排气方法正确、不浪费药；/r/n4．再次核对,绷紧皮肤,持针正确；/r/n5．进针角度、深度适宜；/r/n6．注射剂量准确,皮丘符合要求。/r/n4/r/n4/r/n3/r/n4/r/n5/r/n5/r/n3/r/n3/r/n3/r/n3/r/n4/r/n4/r/n2/r/n2/r/n1/r/n2/r/n3/r/n3/r/n1/r/n1/r/n0/r/n1/r/n2/r/n2/r/n操作后/r/n15/r/n1．向病人交待注意事项正确；〔不远离、不按揉、有不适及时告知/r/n2．用物处置得当/r/n3．准确观察反应〔时间、结果、判断/r/n4．洗手,执行签字。/r/n5/r/n3/r/n5/r/n2/r/n4/r/n2/r/n4/r/n1/r/n3/r/n1/r/n3/r/n0/r/n2/r/n0/r/n2/r/n0/r/n评价/r/n5/r/n严格查对制度和无菌技术。/r/n操作流畅、判断准确。/r/n3/r/n2/r/n2/r/n1/r/n1/r/n0/r/n0/r/n0/r/n提问/r/n5/r/n5/r/n4/r/n3/r/n2/r/n总分/r/n100/r/n提问：1.皮内注射的目的是什么？〔2.5分/r/n2.给病人进行皮内注射应注意些什么？〔2.5分/r/n第二十二项皮下注射技术操作考核评分标准/r/n项目/r/n评分细则/r/n得分及/r/n扣分依据/r/n仪表/r/n评估与指导/r/n了解病情,药物过敏史及局部皮肤状况；/r/n解释指导操作目的及配合、注意事项。/r/n5/r/n5/r/n4/r/n4/r/n3/r/n3/r/n2/r/n2/r/n严格查对制度和无菌技术。/r/n操作流畅,效果好。/r/n5/r/n4/r/n3/r/n2/r/n提问：1.如何对皮下注射的患者进行指导？〔2.5分/r/n2.皮下注射的目的是什么？〔2.5分/r/n第二十三项物理降温技术操作考核评分标准/r/n项目/r/n总分/r/n评分细则/r/n评分等级/r/n仪表/r/n5/r/n仪表端庄,服装整洁。/r/n5/r/n4/r/n3/r/n2/r/n评估与指导/r/n10/r/n1．了解病情、意识状态、局部组织状态、皮肤情况；/r/n2．解释,取得合作；/r/n3．正确指导操作目的、注意事项等/r/n4/r/n3/r/n3/r/n3/r/n2/r/n2/r/n2/r/n1/r/n1/r/n1/r/n0/r/n0/r/n操作前准备/r/n5/r/n2．备齐用物,放置合理。/r/n2/r/n3/r/n1/r/n2/r/n0/r/n1/r/n0/r/n0/r/n操/r/n作/r/n过/r/n程/r/n安全与/r/n舒适/r/n10/r/n环境安静、清洁；〔关门窗,围屏风,调节室温/r/n病人体位舒适,安全；/r/n注意保护病人隐私。/r/n3/r/n4/r/n3/r/n2/r/n3/r/n2/r/n1/r/n2/r/n1/r/n0/r/n1/r/n0/r/n酒/r/n精/r/n拭/r/n浴/r/n55/r/n核对医嘱和病人；/r/n松开盖被不过多暴露；/r/n冰袋、热水袋放置部位正确；/r/n脱衣方法正确；/r/n身下垫毛巾；/r/n拭浴方法正确；/r/n拭浴部位、顺序正确,无遗漏；/r/n酒精浓度和温度适宜；<30%;50/r/n℃/r/n>/r/n拭浴中,注意保护病人的隐私；/r/n观察反应,及时处理；/r/n拭毕穿衣、裤方法正确；/r/n观察体温时间及记录方法正确；/r/n30min/r/n后及时测体温。/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n5/r/n2/r/n3/r/n2/r/n3/r/n5/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n4/r/n1/r/n2/r/n1/r/n2/r/n4/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n3/r/n0/r/n1/r/n0/r/n1/r/n3/r/n0/r/n1/r/n3/r/n0/r/n0/r/n2/r/n2/r/n2/r/n0/r/n0/r/n0/r/n0/r/n2/r/n操作后/r/n5/r/n助病人取舒适体位,整理床单位；/r/n用物处理正确,洗手。/r/n2/r/n3/r/n1/r/n2/r/n0/r/n1/r/n0