MindMap Gallery Neurosurgery Nursing Risk Mind Map
This is a mind map about neurosurgery nursing risks, including disease observation risk management, ward safety risk management, complication risk management, etc.
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Neurosurgery Nursing Risk Management
Disease observation risk management
state of consciousness
glass score
Observe as directed by doctor
Keep accurate records
Timely reporting of exceptions
vital signs
Observe closely
Monitoring records for compliance with medical instructions
Timely reporting of exceptions
Follow doctor’s instructions and handle it promptly
pupil
Be sure to check when taking over the shift
Observe and record according to doctor’s instructions
Report any abnormal changes immediately and observe them from time to time.
Intracranial pressure and CVP monitoring
Observe whether the pipeline is smooth and whether the measurement is accurate
Observe monitoring values and report any abnormalities immediately
body position
Provide appropriate posture according to the condition
Pay attention to return to the original position after measuring cvp
People who have nasogastric feeding should pay attention to the posture before and after nasogastric feeding
Nutrition
Follow the doctor’s advice to provide enteral or parenteral nutrition, and pay attention to the precautions when feeding.
Timely collection of various laboratory specimens
Check that the information is correct
Collect specimens correctly and label accurately
Send for inspection promptly
Pay attention to the results and report any abnormal and critical values immediately
Complication risk management
Nosocomial infection
Respiratory tract infection, ventilator-associated pneumonia
Keep the respiratory tract open and perform strict aseptic suctioning
Strengthen lung care, provide personal guidance, and teach family members to fasten their backs effectively
Take good care of the ventilator tubes and replace the ventilator tubes and humidification fluid as required
urinary tract infection
Follow doctor’s instructions for perineal care
Sterile catheterization
Stop indwelling catheterization as soon as possible
bloodstream infection
Aseptic operation, select channels according to risk level
The condition allows early removal of relevant pathways
Collect blood cultures in a standardized manner and apply antibiotics based on culture results
Multidrug-resistant bacterial infections
Strictly implement the Infection Control Office's "Process for Preventing Multidrug-Resistant Bacterial Infections"
Collect specimens from high-risk patients early
Care for aseptic operations and avoid contamination of infusion lines and materials used
Surgical site dressing, drainage tube observation and care
Strict hand hygiene practices,
Infection control nurses and head nurses check the performance of hand hygiene in the ward at any time
Regular surface and hand hygiene monitoring
Strengthen the education of nursing staff and family members, do not borrow items from each other, and do not visit wards
Wards are disinfected regularly and windows should be opened for ventilation twice a day for 30 minutes each time.
Insufficient hand hygiene facilities in the ward
The patient is in critical condition, has low immunity, and requires many invasive procedures
skin damage
skin pressure injury
Skin assessment
Skin handover is conducted every shift to check the skin condition, and high-risk patients with low scores undergo Brden score daily.
Postural management
Turn over regularly and gently, and increase the use of air mattresses, turning pads, water cushions and soft pillows
Relieve stress
Keep the bed clean, flat, and free of foreign objects to avoid pressure on pipes and debris and reduce pressure on bone protrusions.
Increase nutrition
incontinence dermatitis
Prevent primary disease
Actively treat the underlying disease and solve the problem of fecal and urinary incontinence
Skin assessment
Carry out skin handover every shift to check the skin condition and ensure that the skin is dry and free of moisture.
basic care
When cleaning the skin, use gentle movements and use warm water and non-irritating cotton towel to wipe the skin. You can choose the appropriate skin protectant according to the skin condition.
scald
Assess the patient's skin
Assess the patient's age, state of consciousness and perception
Pay attention to risk point control when applying hyperthermia
Strengthen missionary work and conduct regular inspections
When burns occur, treat the wound promptly to reduce adverse consequences.
Back slap injury
Demonstrate the operation of buckling the back, conduct effect inspections, and strengthen health education
When using the expectorator, use a bath towel to protect your skin
Standardize the use of expectoration machines and prohibit excessive vibration frequency exceeding the maximum range of 20-25hz.
unplanned extubation
Take off the tube
Turn over and straighten the drainage tubes when changing positions, leaving sufficient length to avoid excessive stretching.
The pipe fixing method is correct and secondary fixing is required if necessary.
Follow medical advice when necessary
Sedate as directed by your doctor if necessary
Promote relevant knowledge to family members and obtain cooperation
Make a good transition
blockage extubation
Carry out good care of all channels according to doctor’s instructions
If you have a gastrointestinal tube, please pay attention to the following precautions when performing nasal feeding:
Effectively educate patients and their families on relevant knowledge
lower extremity venous thrombosis
Get out of bed and move around as soon as possible according to your condition
Pneumatic pump prophylaxis (no thrombosis)
Air pressure pump pressure
Avoid skin damage
Elastic bandage, ankle pump exercise, passive massage by family members (no blood clots)
Observe closely and report and record any abnormalities in a timely manner
Drug extravasation, phlebitis
Choose appropriate intravenous access according to the drug
Pay attention to aseptic operation
Use needleless infusion connectors and tees, secure them properly, and replace sterile treatment towels daily.
Observe closely and deal with phlebitis and extravasation promptly
Protect blood vessels
During venipuncture, choose thick, straight, and elastic blood vessels, and use central venous catheters and PICCs if necessary.
Strengthen inspections
When using high-risk special drugs, increase inspections, standardize shift handover procedures, and prevent extravasation.
Emergency treatment
When extravasation of high-risk drugs is discovered, stop instillation immediately, withdraw the extravasated drugs promptly, and apply wet compress treatment with antagonist drugs as directed by the doctor.
If necessary, apply drugs for local sealing treatment as directed by the doctor.
Do a good job of informing and communicating effectively
Ward safety risk management
communicate effectively
medical care
Medical and nursing communication is not timely and the processing of medical orders is delayed
Inconsistent communication between medical staff and patients leaves patients and their families at a loss as to what to do
doctor-patient
Information asymmetry and high expectations of patients and family members
Notified of failure to sign or delay
nurse patient
The patient's condition is urgent, critical, and the family members' emotions are excessive.
Busy at work, informing perfunctorily or not at all
The nurse's information is simple
Choose the right time to communicate, pay attention to your tone and attitude, and be targeted
transport
Proper assessment before transfer
The items are fully stocked and sufficient
Ability to observe and handle the condition of transport personnel
Family members explain, gain understanding and cooperation
Fall out of bed
Patient is agitated
Follow doctor's orders
Sedate as directed by your doctor
physical disorder
Bed stalls are not placed properly
Ward inspection
Do a good job in missionary work
fall
Physical movement disorder
The ground is slippery
drugs, instruments
Are medicines and equipment in sufficient reserve and qualified?
Do medical staff know the exact location?
Are medical staff skilled in using it?
nursing documents
Strengthen legal awareness and realize the importance of nursing documents
Have a sense of self-protection
Objective, truthful and accurate writing
Records should be timely and comprehensive
The record is not focused and lacks expertise
Strengthen professional knowledge training
There is copy and paste
Strengthen quality control
Human resources allocation
Pay attention to manpower allocation during key periods and implement flexible scheduling
Reasonable matching of nurses’ levels
Reasonable distribution of workload
medical environment
Electricity and fire safety
Safety inspection of traditional Chinese medicine treatment room
Use of electrical appliances in wards
Medical training and drills
Check and preach every day
There are safety warning signs on the floor of the ward and public restrooms. If there are any water stains, clean them up promptly.
If patients raise concerns in restaurants, elevators, etc., report them to the relevant departments in a timely manner and resolve them as soon as possible.
At present, the degree of trust between doctors and patients is not high, and patients' awareness of rights protection has increased, and they have strengthened their notifications that they must sign when necessary.
Protect patient privacy
Standardized charges
All medical staff are familiar with medical insurance price policies and implement them in a standardized manner
Explain patiently