50 basic nursing knowledge that you must master as a nurse

1. What are the steps of the care procedure?

The nursing process consists of five steps: assessment, diagnosis, planning, implementation, and evaluation.

2. What are the methods of data collection?

(1) observation; (2) conversation; (3) Physical examination; (4) Consult relevant information.

3. What is the appropriate temperature and humidity in the ward?

(l) The temperature of the ward should be kept at 18-22°C. For neonates and elderly patients, it is advisable to keep the room temperature at 22-24°C.

(2) The humidity of the ward is generally maintained at 50%-60%.

4. What are the commonly used lying positions? Which patients are they suitable for?

(1) Occipital supine position: suitable for patients who are unconscious or unawake under general anesthesia; Patients after neuraxial anesthesia or spinal puncture.

(2) Concave decubitus position: suitable for patients with shock.

(3) Supine position with knees bent: suitable for patients with abdominal examination or receiving catheterization and perineal irrigation.

(4) Lateral decubitus position: suitable for patients with enema, anal examination and gastroscopy and colonoscopy; Patients with intramuscular injection into the buttocks.

(5) Semi-sitting and recumbent position: suitable for patients with dyspnea caused by cardiopulmonary diseases; Patients who have undergone thoracic, abdominal, or pelvic surgery or have inflammation; Certain patients after facial and neck surgery; Patients with weak constitution during the convalescent period.

(6) Upright sitting position: suitable for patients with heart failure, pericardial effusion, and bronchial asthma attack.

(7) Prone position: suitable for patients with low back examination or pancreatic and cholangiogram examinations; Patients who have wounds on the waist, back, and buttocks after spine surgery and cannot lie flat or on their sides; Patients with abdominal pain due to flatulence.

(8) Head and foot high: suitable for patients with lung secretion drainage; Patients undergoing duodenal drainage; Patients with premature rupture of membranes during pregnancy; Patients with traction of calcaneal or tibial tuberosity.

(9) High head and low feet: suitable for patients with cervical spine fracture and skull traction; Patients after cranial surgery.

(10) Knee-thoracic position: suitable for patients with anorectal, rectal, sigmoidoscopy and treatment; Patients who need to correct fetal malposition or retroverted uterus; Promotes postpartum uterine recovery.

(11) Lithotomy position: suitable for patients with perineum and anal examination, treatment or surgery, and maternal delivery.

5. What are the precautions for special patients when changing the recumbent position?

(1) For those who have various catheters or infusion devices, the catheter should be placed properly first, and carefully checked after turning over to keep the catheter unobstructed.

(2) For those with cervical spine or skull traction, do not relax the traction when turning over, and keep the head, neck, and trunk in the same horizontal position and turn over; After turning over, pay attention to the traction direction, position and traction force is correct.

(3) For craniocerebral surgery, the healthy side should be decubitated or flat, and the head should not be turned violently when turning over, so as not to cause brain herniation, compress the brainstem, and lead to sudden death of the patient.

(4) For those with cast, attention should be paid to the location of the affected area and the blood circulation of some limbs after turning over to prevent compression.

(5) For general surgeons, when turning over, they should first check whether the dressing is dry and whether it falls off, if the secretion is soaked in the dressing, the dressing should be changed and fixed properly before turning over, and the wound should not be compressed after turning over.

6. What are the precautions when using restraints?

(1) Strictly grasp the indications for application and pay attention to maintaining patients' self-esteem.

(2) Explain the purpose, operation points, and precautions of using restraints to patients and their families to gain understanding and cooperation.

(3) The restraint can only be used for a short period of time, and is released regularly to assist the patient to change positions frequently.

(4) The limb is in a functional position when used; The padding under the restraint belt should be padded and the tightness should be appropriate; Closely observe the color of the skin in the restraint area, and apply a topical massage if necessary to promote blood circulation.

(5) Record the reason, time, observations, nursing measures and time of release of restraint.

7. What is the assessment of pain?

(1) the location of the pain; (2) the duration of pain; (3) the nature of the pain; (4) the degree of pain; (5) the expression of pain; (6) factors influencing pain; (7) The effect of pain on the patient, whether there are accompanying symptoms, etc.

8. What are the commonly used pain assessment tools?

(1) digital assessment method; (2) textual descriptive evaluation method; (3) visual analogue evaluation method; (4) Facial expression measurement chart.

9. How can I use the 0-5 textual description method to assess pain?

Grade 0 painless.

Grade 1 mild pain: tolerable, able to live and sleep normally.

Grade 2 moderate pain: mild sleep disturbance requiring analgesics.

Level 3. Severe pain: disturbs sleep and requires narcotic analgesics.

Grade 4 severe pain: severe sleep disturbance with other symptoms.

Grade 5 intolerable: severe disturbance of sleep with other symptoms or passive position.

10. What are the stages of pressure ulcers? Briefly describe why it happens.

According to its severity and depth of damage, it can be divided into four stages: (1) the bruising and ruddy stage; (2) inflammatory infiltration phase; (3) superficial ulcer stage; (4) Necrotic ulcer stage.

Causes:

(1) Local long-term pressure, friction or shear force.

(2) The local area is often pricked by moisture or excrement.

(3) Improper use of plaster bandages and splints.

(4) Systemic malnutrition or edema.

11. Briefly describe the scale of the body's mobility.

0 degrees: completely independent and free to move.

Grade 1: Requires the use of equipment or instruments (e.g., crutches, wheelchairs).

2nd degree: need for help, guardianship, and education from others.

3rd degree: need both help and equipment and instruments.

4th degree: Completely unable to be independent and unable to participate in activities.

12. Briefly describe the grading of muscle strength.

Grade 0: Complete paralysis with complete loss of muscle strength.

Grade 1: Slight muscle contraction but no limb movement may be seen.

Level 2: Movable position but not lifted.

Grade 3: The limb can be lifted away but cannot resist resistance.

Grade 4: Able to do exercises against resistance, but weakened muscles.

Grade 5: Normal muscle strength.

13. How is pulse rate measured for a patient with a short pulse?

To measure the pulse rate for patients with shortness of pulse, two people should measure it at the same time, one person listens to the heart rate, the other person measures the pulse rate, and the two people start at the same time, and the person who listens to the heart rate issues the "start" and "stop" password, and the time is l minute.

14. What are the precautions for measuring blood pressure?

(1) Regularly test and calibrate the sphygmomanometer.

(2) For those who need to closely observe blood pressure, four determinations should be achieved, namely, fixed time, fixed position, fixed position, and fixed blood pressure monitor.

(3) If the blood pressure is found to be difficult or abnormal, it should be retested.

(4) Pay attention to the error of blood pressure measurement caused by factors such as manometry device (sphygmomanometer, stethoscope), measurer, examinee, measurement environment and other factors to ensure the accuracy of blood pressure measurement.

15. What are the effects of too loose and too tight cuffs on blood pressure when measuring blood pressure?

(1) If the cuff is wrapped too loosely, the air bag can be balloon-shaped, the effective measurement area will be narrowed, and the measured blood pressure value will be high.

(2) If the cuff is wrapped too tightly, the blood vessels can be compressed before the air is injected, and the measured blood pressure value is low.

16. What is tidal breathing?

Tidal breathing refers to breathing from shallow slow to deep and fast and then from deep to shallow and slow, after a period of pause in breathing (5^-3). seconds), and repeat the above periodic breathing, repeating the cycle like the ebb and flow of the tide.

17. What are the contraindications to cold therapy? Why?

(1) Postoccipital back, auricle, scrotum: to prevent frostbite.

(2) Precordial area: to prevent reflex heart rate slowing, atrial fibrillation or atrioventricular block.

(3) Abdomen: in case of diarrhea 0

(4) Plantar: to prevent reflex peripheral vasoconstriction from affecting heat dissipation or causing transient coronary artery constriction.

18. What are the contraindications to hyperthermia?

(1) Acute abdominal pain without a clear diagnosis.

(2) Infection of the risk triangle of the face.

(3) Bleeding from various organs.

(4) The initial stage of soft tissue injury or sprain (within 48 hours).

(5) Skin eczema.

(6) Acute inflammatory reactions, such as heel inflammation, otitis media, and conjunctivitis.

(7) Metal graft site.

(8) Location of malignant lesions.

19. What should be evaluated before nasogastric feeding?

(1) Whether the gastric tube is in the stomach and smooth, and the gastric tube can be injected only after confirming that the gastric tube is in the stomach.

(2) If there is no gastric storage, if the gastric contents are > 100ml, nasogastric feeding will be suspended.

20. What is the 24-hour urine output of a normal person? What are polyuria, oliguria, anuria?

The urine output of a normal person in 24 hours is about 1000-2000ml, with an average of 1500ml.

Polyuria: refers to a 24-hour urine output that often exceeds 2500ml.

Oliguria: refers to a urine output of less than 400ml in 24 hours or less than 17ml in urine per hour.

Anuria: also known as urinary closure, refers to the amount of urine less than 100ml in 24 hours or no urine in 12 hours.

21. Briefly describe the collection method of 24-hour urine samples.

(1) Empty the arm at 7 a.m., collect all the urine thereafter in a large clean container (such as clean sputum), and at 7 a.m. the next day, the last urine will be discharged into the container, measure the total amount and record it on the test sheet.

(2) Mix all the specimens evenly, take out about 20ml of specimens from them, and put them in a clean and dry container for testing as soon as possible.

(3) For some special tests, preservatives need to be added according to the specific situation.

22. What are the common pathological changes in urine color in clinical practice?

(1) Hematuria: The depth of color is related to the amount of red blood cells contained in the urine.

(2) Hemoglobinuria: A large number of red blood cells are destroyed in the blood vessels, showing a strong brown color and soy sauce-like color.

(3) Bilirubinuria: the urine is dark yellow or yellow-brown, and the foam is also yellow after shaking the urine.

(4) Celiuria: The urine contains lymph and is milky white.

(5) Pyuria: The urine contains pus, which is white and flocculent and turbid, and the pus contained in it can be seen.

23. What are the nursing measures for acute urinary retention?

(1) Reason for cancellation.

(2) Promote urination: induce urination for postoperative urine retention patients, catheter under aseptic operation if necessary, and do a good job in the care of urethral catheter and urethral opening. For those who have undergone suprapubic bladder puncture or suprapubic cystostomy, the cystostomy tube should be well cared for and kept open.

(3) Avoid bladder bleeding: the amount of urine should not exceed 1000ml at a time, so as not to cause bladder bleeding.

24. What are the key points of skin care for patients with urinary incontinence?

(1) Keep the sheets clean, flat and dry.

(2) Clean the perineal skin in time, keep it clean and dry, and apply skin protector if necessary.

(3) Corresponding protective measures should be taken according to the condition, male patients can use urine condoms, female patients can use urine pads, urine collectors or indwelling urinary catheters.

25. What principles should be followed when administering the drug?

(1) Accurate administration according to the doctor's instructions: strictly implement the doctor's instructions, and the doubtful doctor's instructions should be clearly understood before administration, so as to avoid blind implementation.

(2) Strictly implement the "three checks and seven pairs" system.

(3) Safe and correct administration: reasonably grasp the time and method of administration, and distribute and use the drug in time after it is prepared. Explain and give medication instructions before dosing. For drugs that are prone to allergic reactions, be aware of the allergy history before use.

(4) Observation of drug reactions: drug efficacy, adverse reactions, changes in the patient's condition, dependence on drugs, emotional reactions, etc.

26. What are the precautions when administering the drug orally?

(1) The medicine that needs to be swallowed is usually taken with warm boiled water at 40-60 °C, and not with tea.

(2) Drugs that have a corrosive effect on dental steps, such as acids and irons, should be sucked with a straw and rinsed to protect the teeth.

(3) Sustained-release tablets, enteric-coated tablets, and capsules should not be chewed when swallowed.

(4) The sublingual lozenge should be placed under the tongue or between the cheek membrane and the tooth to be dissolved.

(5) Antibiotics and sulfonamides should be taken on time to ensure effective blood concentration.

(6) It is not advisable to drink water immediately after taking drugs that have a soothing effect on the mucous membrane of the respiratory tract. The information comes from the ICU Nursing Home's WeChat public account, so stay tuned.

(7) Some sulfonamides are excreted through the kidneys, and when the urine is small, it is easy to precipitate crystals and block the renal tubules, so drink more water after taking the medicine.

(8) In general, stomach medicine should be taken before meals, digestive aids and drugs that irritate the gastric mucosa should be taken after meals, and hypnotic drugs should be taken before bedtime.

27. What are the precautions for oral iron therapy?

(1) In order to reduce gastrointestinal reactions, it can be taken after or during meals, starting with a small dose and gradually increasing to a sufficient amount.

(2) Liquid iron can make teeth black, and can be taken with a straw or dropper.

(3) Iron can be combined with vitamin C; , juice and other servings to facilitate absorption; Do not take with foods that inhibit iron absorption.

(4) After taking iron supplements, the stool becomes black or tarry. If the drug is discontinued, the patient should be explained to the cause and the concern should be allowed.

(5) Take the medicine according to the dosage and course of treatment, and regularly review the relevant laboratory tests.

28. What are the commonly used oral care solutions? What does each do?

Normal saline cleans the mouth and prevents infection; 1%-3% hydrogen peroxide solution is antiseptic and deodorant, and is suitable for oral infections with ulceration and necrotic tissues

1% to 4% sodium bicarbonate solution alkaline solution, suitable for fungal infections

0.02% chlorhexidine solution cleans the oral cavity and is broad-spectrum antibacterial

0.02% furacilin solution cleans the oral cavity and is broad-spectrum antibacterial

0.1% acetic acid solution is indicated for Pseudomonas aeruginosa infection

2% to 3% N boric acid solution acidic preservative, antibacterial

0.08% metronitronis solution is suitable for anaerobic infections

29. What are the different types of oxygen therapy? What kind of patients are they suitable for?

(1) Low-concentration oxygen therapy: the oxygen concentration < 40%. Suitable for: patients with hypoxemia with carbon dioxide retention, such as chronic obstructive pulmonary disease.

(2) Moderate concentration oxygen therapy: the oxygen concentration is 40%-60%0 is suitable for patients with obvious ventilation/perfusion ratio imbalance or significant diffusion disorder, such as pulmonary edema, myocardial infarction, shock, etc.

(3) High-concentration oxygen therapy: the oxygen concentration > more than 60%. It is indicated for patients with isolated hypoxia and no carbon dioxide storage, such as adults with respiratory distress syndrome and life support after cardiopulmonary resuscitation.

(4) Hyperbaric oxygen therapy: refers to the inhalation of 100% oxygen at a pressure of 2-3kg/cm2 in a special pressurized chamber, such as carbon monoxide poisoning, gas gangrene, etc.

30. Briefly describe the precautions for oxygen therapy.

(1) Pay attention to the cause.

(2) Keep the airway open.

(3) Choose the appropriate oxygen therapy method.

(4) Pay attention to humidification and heating.

(5) Replace and disinfect regularly to prevent contamination and catheter blockage.

(6) Evaluation of the effect of oxygen therapy.

(7) Prevent explosion and fire.

31. How is oxygen concentration and oxygen flow rate converted?

氧气浓度(%)=21+4*氧流量(L/min)

32. What are the precautions for oxygen aerosol inhalation?

(1) Use the oxygen supply device correctly, pay attention to the safety of oxygen, and do not hold water in the oxygen humidification bottle, so as not to dilute the liquid medicine and affect the efficacy.

(2) During nebulization, instruct the patient to inhale deeply through the mouth and hold the breath for 1---2 seconds, exhale through the nose, and the oxygen flow rate is 6-8L/min.

(3) Pay attention to the patient's sputum discharge, and assist the patient to clean the oral cavity after nebulization.

33. What are the clinical manifestations of penicillin anaphylactic shock?

(1) Symptoms of airway obstruction: chest tightness, shortness of breath and a sense of impending death.

(2) Symptoms of circulatory failure: paleness, cold sweat, giving, weak pulse, drop in blood pressure, irritability, etc.

(3) Central nervous system symptoms: dizziness, numbness of the face and limbs, loss of consciousness, convulsions, incontinence, etc.

(4) Other allergic reactions: urticaria, nausea, vomiting, abdominal pain and diarrhea.

34. Briefly describe the first aid nursing measures for penicillin anaphylactic shock.

(1) Stop the drug immediately and make the patient lie flat on the spot.

(2) Immediate subcutaneous injection of 0.1% epinephrine hydrochloride. 0.5-1ml, patients should reduce. If the symptoms are not relieved, 0.5ml of the drug can be injected subcutaneously or intravenously every 30min.

(3) Oxygen inhalation. When breathing is suppressed, mouth-to-mouth rescue respiration should be performed immediately with intramuscular injection of respiratory stimulants. When laryngeal edema interferes with breathing, endotracheal intubation or tracheostomy should be performed immediately.

(4) Anti-allergic.

(5) Correction of acidosis and administration of antihistamines as prescribed.

(6) In case of cardiac arrest, cardiopulmonary resuscitation should be performed immediately.

(7) Closely observe vital signs, urine output and other changes in the condition, pay attention to keeping warm, and make a dynamic record of the condition. Patients should not be moved until they are out of danger.

35. How are venipuncture tools classified?

According to the type of blood vessel in which the catheter is placed, it can be divided into: peripheral venous catheter and central venous catheter. According to the length of the catheter, it can be divided into: short catheter, medium length catheter, and long catheter.

36.How to flush and seal the indwelling intravenous catheter?

(1) Flushing method: The flushing solution is usually normal saline, and the pulse flushing method is adopted. Peripheral indwelling needles can be flushed with a 5ml syringe; PICC catheters should be flushed with a syringe of more than 10 ml. The minimum amount of flush fluid should be 2 times the capacity of the catheter and attachments.

(2) Sealing method: (1) Steel needle method: leave the tip of the needle in the heparin cap a little, and when 0.5-1ml of the sealing solution is left in the pulse bolus, pull out the needle while pushing the sealing solution (the pushing speed is greater than the needle pulling speed), so as to ensure that the indwelling catheter is filled with sealing solution, so that there is no liquid medicine or blood in the catheter. (2) Needle-free joint method: After flushing, the small clip is as close to the puncture point as possible before the syringe is removed, and the syringe is removed after the clamp is completed.

37. What are the clinical manifestations of common infusion reactions?

(1) Febrile reaction: It usually occurs a few minutes to 1 hour after the infusion of the plant. Presents with chills, chills, and fever. The body temperature of mild patients is about 38°C, and it can return to normal within a few hours after stopping the infusion; In severe cases, chills are initially onset, followed by high fever, body temperature can reach more than 40°C, and accompanied by systemic symptoms such as headache, nausea, vomiting, and pulse rate.

(2) Acute pulmonary edema: the patient suddenly has dyspnea, chest tightness, cough, cough pink frothy sputum, and sputum can gush out of the mouth and nose in severe cases. Auscultate the lungs with wet gong sounds, and the heart rate is fast and irregular.

(3) Phlebitis: cord-like red lines appear along the direction of the veins, and local tissues are red, swollen, burning, painful, sometimes accompanied by systemic symptoms such as chills and fever.

(4) Air embolism: the patient feels abnormal discomfort in the chest or has retrosternal pain. Dyspnea and severe seizures followed, accompanied by a sense of near-death. Auscultation of the precordial area may reveal a loud, persistent "blister sound".

38. Briefly describe the causes of acute pulmonary edema in infusion and the treatment measures.

Cause:

(1) The infusion speed is too fast, and too much fluid is transfused in a short period of time, which increases the circulating blood volume sharply and causes the heart to be overloaded.

(2) The patient's original cardiopulmonary function is poor.

Measures:

(1) Immediately stop the infusion and notify the doctor for emergency treatment. If the condition allows, the patient can be allowed to sit upright with his legs drooping to reduce venous return in the lower limbs and reduce the burden on the heart.

(2) Give the child high-flow oxygen inhalation, the general oxygen flow rate is 6-8L/min, and at the same time, add 20% ---30% ethanol solution to the humidification bottle.

(3) Give sedative, antiasthmatic, cardiotonic, diuretic and vasodilator drugs according to the doctor's instructions.

(4) Carry out limb rotation if necessary. Proper compression with a rubber tourniquet or sphygmomanometer cuff to block venous blood flow, and take turns to relax the tourniquet on a limb every 5-10min can effectively reduce the amount of venous blood returning to the heart. After symptoms are relieved, the tourniquet is gradually lifted.

39. What position should the patient be positioned in the event of an air embolism during the infusion? Why?

The patient should be placed in the left lateral decubitus position with the head down and feet high. This position allows the air to float to the tip of the right ventricle, avoiding the pulmonary artery population, and as the heart contracts, the air is mixed into a foam, which is gradually absorbed into the human pulmonary artery in small amounts.

40. What are the precautions for the use of mannitol?

(l) It is strictly forbidden to inject intramuscularly or subcutaneously to avoid subcutaneous edema or tissue necrosis caused by drug leakage.

(2) It cannot be mixed with other drugs intravenously.

(3) During intravenous infusion, it is advisable to use a large needle, and 250ml of liquid should be intravenously dripped within 20-30min.

(4) In the process of applying the dehydrating agent, the volume, blood pressure, pulse, and respiration should be closely observed, and records should be made.

(5) It can cause rapid increase in blood volume, and it is forbidden for patients with cardiac insufficiency and acute pulmonary edema.

41. According to the type of antigen on the red blood cell membrane. What are the different types of blood types?

(1) Type A: Those who have only A antigen on the red blood cell membrane.

(2) Type B: Those who have only B antigen on the red blood cell membrane.

(3) Type AB: Those with two antigens, A and B, on the red blood cell membrane.

(4) Type O: those who have neither A antigen nor B antigen on the red blood cell membrane.

42. What are the precautions for component transfusion?

(1) Some components of blood, such as white blood cells, platelets, etc. (except red blood cells), have a short survival period, and fresh blood is appropriate, and must be transfused into the human body within 24 hours (from the time of blood collection).

(2) In addition to plasma and albumin preparations, all other blood components need to be cross-matched before transfusion.

(3) Give anti-allergic drugs according to the doctor's instructions before blood transfusion.

(4) If the patient needs to transfuse whole blood at the same time as component blood. Component blood should be transfused first, followed by whole blood, to ensure that the component blood can exert the best effect.

43. What are the common transfusion reactions?

(1) Febrile reaction; (2) allergic reactions; (3) hemolytic reactions; (4) Massive transfusion reactions;

(5) bacterial contamination reaction; (6) Diseases, infections, etc.

44. What should I do if I have an allergic reaction to a blood transfusion?

(1) Mild allergic reactions, slowing down blood transfusion, and giving anti-allergic drugs.

(2) For moderate and severe allergic reactions, blood transfusion should be stopped immediately and 0.1% epinephrine should be injected subcutaneously. 0.5-1ml, intravenous injection of anti-allergic drugs such as dexamethasone.

(3) Patients with dyspnea should be given oxygen inhalation, and tracheotomy should be performed for severe laryngeal edema.

(4) Patients with circulatory failure should be given anti-shock therapy.

45. What are the causes of hemolytic reactions in blood transfusion? How to deal with it?

Cause:

(1) Abnormal blood transfusion.

(2) Transfusion of spoiled blood.

(3) Rh factor-induced hemolysis.

Measures:

(1) Stop the blood transfusion immediately and notify the doctor.

(2) Give oxygen inhalation, establish intravenous access, and give vasopressors or other drug treatment according to the doctor's instructions.

(3) Send the remaining blood, the patient's blood sample and urine specimen to the laboratory for examination.

(4) Seal both sides of the waist, and apply hot water bottles to both kidney areas to relieve tubular spasm and protect the kidneys.

(5) Alkalinized urine: intravenous injection of sodium bicarbonate solution.

(6) Closely observe vital signs and urine output, insert a urinary catheter, measure the hourly urine output, and make a record.

(7) If symptoms of shock appear, anti-shock treatment should be carried out.

(8) Psychological nursing: comfort patients and eliminate their tension and fear.

46. What are the main contents of medical observation?

(1) Observation of general conditions: development and body shape, diet and nutritional status, face and expression, body position, posture and gait, skin and mucous membranes, etc.

(2) Observation of vital signs.

(3) Observation of the state of consciousness.

(4) Observation of the pupil.

(5) Observation of mental state.

(6) Observation of special examinations or medications.

(7) Observation of secretions, excretions and vomit.

47. How can different degrees of impaired consciousness be judged?

(1) Drowsiness: the mildest degree of consciousness impairment. People who suffer from vapor are in a state of continuous sleep, but can be awakened by words or mild stimuli, can answer questions correctly, simply and slowly after waking up, but are slow to respond, and fall asleep soon after stopping stimulation.

(2) Confusion: the degree is deeper than drowsiness. Presents with disorientation, incoherent thinking and language, and may include delusions, hallucinations, restlessness, delusion, or confusion.

(3) Drowsiness: The patient is in a state of deep sleep and is not easy to wake up. However, it can be awakened by strong stimuli such as compressing the supraorbital nerve and shaking the body, and after waking up, the answer is slurred or the answer is not the question, and the stimulation is stopped and then enters a state of deep sleep.

(4) Shallow coma: most of the consciousness is lost, there is no voluntary activity, there is no response to light and sound stimuli, and there may be painful expressions or defensive reactions such as limb withdrawal in response to painful stimuli.

(5) Deep coma: complete loss of consciousness and no response to various stimuli.

48. How can I tell my pupil size?

In natural light, the diameter of the pupil is 2-5mm, and the average is 3-4mm.

In pathological cases, pupil diameter less than 2 mm is miosis, and less than Imm is needle-like pupil. A pupil diameter greater than 5 mm is considered mydriasis.

49. What are the clinical manifestations of lower extremity deep vein thrombosis? How can it be prevented?

Clinical presentation:

(1) Swelling of the affected limb with increased skin temperature.

(2) Local severe pain or tenderness.

(3) Humans' sign is positive, and excessive dorsiflexion test can cause severe pain in the lower leg.

(4) Superficial vein dilation.

Precautionary measures:

(1) Appropriate exercise to promote venous return. For patients who are bedridden and immobilized for a long time, strengthen bed movement; Early postoperative ambulation; If the blood is in a hypercoagulable state, anticoagulant drugs can be used prophylactically.

(2) Protect the veins: For long-term infusion, the veins should be protected as much as possible and repeated punctures at the same site should be avoided. Try to avoid intravenous fluids in the lower extremities.

(3) Quit smoking.

(4) Eat a low-fat, high-fiber diet to keep your stool smooth.

50. What are the basic principles that should be followed for documentation of care?

(1) Timely: Nursing records must be timely, not delayed or early, and cannot be omitted or misremembered, so as to ensure the timeliness of the records. If it cannot be recorded in time due to rescue, it shall be made up within 6 hours after the end of the rescue, and the time of asking and making up the record when the rescue is completed shall be indicated.

(2) Accurate: The content is true and correct, and the recorded time should be the actual time of administration, treatment and nursing.

(3) Complete: The eyebrow column and page number must be filled in completely. Records are continuous, with no blanks. Sign the full name after each record.

(4) Concise: focused, concise, fluent, using medical terminology and recognized abbreviations.

(5) Clear: Write with red and blue pens as required, with clear handwriting, upright fonts, and keep them neat, and shall not alter, cut and paste and abuse simplified words.

Source: Angel Station