304烧伤外科新护士临床护理手册

本书系统介绍了烧伤专科新护士上岗需要掌握的基本知识与技能，如护理职业相关法律、法规，护士岗位职责与工作要求，护士执业规划，护士职业礼仪，护患沟通，临床必备基础知识、质量管理与常用护理技术操作考核及各种常见应急事件处理预案等。

第一部分　专科临床护理 ·················································································1 一、烧伤基础知识 ····················································································1 二、烧伤急救护理 ····················································································4 三、烧伤入院护理 ····················································································6 四、烧伤基础护理 ····················································································9 五、烧伤创面护理 ··················································································13 六、围手术期护理 ··················································································22 七、特殊部位烧伤护理 ············································································31 八、特殊原因烧伤护理 ············································································34 九、特殊年龄烧伤护理 ············································································38 十、吸入性损伤护理 ···············································································45 十一、烧冲复合伤护理 ············································································48 十二、大面积烧伤护理 ············································································49 十三、批量烧伤护理 ···············································································57 十四、烧伤转运护理 ···············································································59 十五、烧伤康复护理 ···············································································61 十六、烧伤出院护理 ···············································································68 第二部分　专科临床护理技能（基础篇） ··························································70 一、静脉输液 ························································································70 二、皮内注射 ························································································73 三、肌内注射 ························································································74 四、皮下注射 ························································································77 五、导尿术（男性、女性患者） ································································78 六、心肺复苏（单人、双人） ···································································81 七、中心管道吸氧法 ···············································································82 八、中心管道吸痰法 ···············································································83 九、经口腔冲洗式口护吸痰法 ···································································85 十、膀胱冲洗 ························································································87 十一、卧床患者更换床单法 ······································································89 十二、静脉采血法（注射器、真空采血针） ·················································91 十三、动脉采血法（注射器、血气针） ·······················································92 十四、灌肠法 ························································································94 十五、留置胃管法 ··················································································98 十六、鼻饲法 ························································································99 十七、心电监护仪的应用 ········································································101 十八、中心静脉压测定 ···········································································102 十九、微量泵的应用 ··············································································103 二十、输液泵的应用 ··············································································105 第三部分　专科临床护理技能（专科篇） ·························································107 一、创面涂药法 ····················································································107 二、眼部滴药法 ··················································································108 三、鼻部滴药法 ····················································································110 四、耳部滴药法 ····················································································111 五、小儿口服给药法 ··············································································112 六、翻身床双人操作法 ···········································································114 七、悬浮床 ··························································································117 八、营养泵 ··························································································118 九、红光治疗仪 ····················································································119 十、半导体激光治疗仪 ···········································································121 十一、远红外线烤灯 ··············································································122 十二、振动排痰仪 ·················································································123 十三、亚低温治疗仪（降温毯） ·······························································125 十四、负压封闭引流技术 ········································································126 十五、PDA ··························································································127 十六、呼吸机 ·······················································································128 十七、GEM Premier 3000血气分析仪 ·························································129 十八、费森尤斯血透机 ···········································································131 十九、动脉血压监测 ··············································································133 二十、PICC置管 ···················································································134 第四部分　应急抢救预案及处置流程 ·······························································137 一、呼吸机使用过程中发生故障应急预案及处置流程 ····································137 二、呼吸机脱机后非计划拔管应急预案及处置流程 ·······································138 三、气管导管意外脱管抢救预案及处置流程 ················································139 四、气管套管堵塞抢救预案及处置流程 ······················································141 五、输液过程中出现肺水肿应急预案及处置流程 ··········································142 六、患者发生静脉空气栓塞应急预案及处置流程 ··········································142 七、血管活性药物外渗应急预案及处置流程 ················································143 八、患者发生躁动应急预案及处置流程 ······················································144 九、患者坠床、摔倒应急预案及处置流程 ···················································145 十、监护室突遇断电应急预案及处置流程 ···················································146 十一、护患纠纷应急处理预案及处置流程 ···················································148 十二、医疗锐器损伤应急预案及处置流程 ···················································148 十三、烧伤休克抢救预案及处置流程 ·························································149 十四、心搏呼吸骤停抢救预案及处置流程 ···················································151 十五、猝死抢救预案及处置流程 ·······························································152 十六、急性心肌梗死抢救预案及处置流程 ···················································154 十七、快速性心律失常抢救预案及处置流程 ················································155 十八、急性左心衰竭抢救预案及处置流程 ···················································157 十九、心源性休克抢救预案及处置流程 ······················································158 二十、高血压脑病及高血压危象抢救预案及处置流程 ····································159 二十一、急性呼吸窘迫综合征抢救预案及处置流程 ·······································160 二十二、咯血抢救预案及处置流程 ····························································161 二十三、重度哮喘抢救预案及处置流程 ······················································162 二十四、肺栓塞抢救预案及处置流程 ·························································164 二十五、烧伤合并急性呼吸衰竭抢救预案及处置流程 ····································165 二十六、烧伤后上消化道大出血抢救预案及处置流程 ····································166 二十七、肝性脑病抢救预案及处置流程 ······················································167 二十八、脑疝抢救预案及处置流程 ····························································168 二十九、脑出血抢救预案及处置流程 ·························································169 三十、癫痫大发作抢救预案及处置流程 ······················································171 三十一、癫痫持续状态抢救预案及处置流程 ················································172 三十二、患者出现精神症状应急预案及处置流程 ··········································174 三十三、过敏性休克抢救预案及处置流程 ···················································175 三十四、溶血反应抢救预案及处置流程 ······················································176 三十五、烧伤合并急性肾衰竭抢救预案及处置流程 ·······································177 三十六、电击伤血管破裂大出血抢救预案及处置流程 ····································178 三十七、烧伤合并弥散性血管内凝血抢救预案及处置流程 ······························179 三十八、患者发生误吸应急预案及处置流程 ················································180 三十九、烧伤合并高钠血症抢救预案及处置流程 ··········································181 四十、烧伤合并高血糖抢救预案及处置流程 ················································182 四十一、高热患者降温抢救预案及处置流程 ················································183 四十二、侵袭性感染与创面脓毒症抢救预案及处置流程 ·································184 四十三、创面侵袭性真菌感染抢救预案及处置流程 ·······································185 四十四、静脉导管感染抢救预案及处置流程 ················································185 四十五、大手术后未清醒患者抢救预案及处置流程 ·······································186 四十六、俯卧翻身床发生窒息抢救预案及处置流程 ·······································187 四十七、卧翻身床发生坠床抢救预案及处置流程 ··········································188 四十八、卧悬浮床发生电解质紊乱抢救预案和处置流程 ·································189 第五部分　重症监护室制度 ···········································································190 一、烧伤整形科监护室规章制度 ·······························································190 二、重症监护单元质量评价标准 ·······························································193 三、烧伤监护室收治范围与转出指征 ···························