特級護理質量考核標準,,,

序號,檢查內容,存在問題,分值

1,標識1.0,1.1床頭卡未標記，標記不清，有涂改，標記有誤,0.25

,,1.2一覽卡未標記，標記不清，有涂改，標記有誤,0.25

,,1.3溫馨提示卡未按要求,0.25

,,1.4患者未佩戴腕帶、腕帶相應顏色不正確、患者信息字跡不清、有涂改、無手術名稱,0.25

2,床單元1.0,2.1病床不整潔，如床體有血漬、污漬，未按要求終末消毒,0.2

,,2.2病床有不安全因素，如床鎖、床檔、搖把等配件損壞未報修,0.2

,,2.3床單不整潔、不干燥、不平整、未將床墊包上,0.2

,,2.4床上有多余物品,0.1

,,2.5床下有多余物品，便器里有剩余尿液未倒凈,0.1

,,2.6床頭桌不整潔,0.1

,,2.7輸液架不整潔,0.1

3,功能帶1.0,3.1吸痰、吸氧裝置損壞未及時報修或未有警示標識,0.25

,,3.2一次性吸痰器、氧氣濕化瓶用后未撤除,0.25

,,3.3功能帶有灰塵或存在膠布痕跡,0.25

,,3.4功能帶存在非醫療用品,0.25

4,患者1.0,4.1患者（根據病情）未穿病人服,0.2

,,4.2非探視時間有家屬探視,0.2

,,4.3有家屬自帶陪床,0.2

,,4.4胡須長、批（趾）甲長,0.2

,,4.5頭發、面部、皮膚、手足、口腔、會陰不清潔，有異味、有血、尿便及膠布痕跡,0.2

5,記錄單1.0,5.1無重癥患者記錄單,0.1

,,5.2提前記錄、未及時記錄,0.1

,,5.3生命體征記錄不準確（如起搏心率記錄次數不準確）,0.1

,,5.4生命體征記錄與體溫單不符,0.1

,,5.5監測指標記錄不準確、與病情不符,0.1

,,5.6護理記錄與醫生病程記錄不符,0.1

,,5.7未按護理文件書寫規范記錄,0.1

,,5.8護理等級量表、高危患者評估單示及時評估,0.1

,,5.9記錄單有涂改,0.1

,,5.10記錄單未簽字、未蓋章,0.1

6,管路1.0,6.1各種管路未有標識、標識不清,0.2

,,6.2各種管路固定不妥善、不潔、脫管、堵管,0.2

,,6.3各種管路、引流袋（盒、球）放置位置不當,0.2

,,6.4各種引流袋、盒未按要求及時更換,0.2

,,6.5各種引流液未及時倒掉,0.2

序號,檢查內容,存在問題,分值

7,儀器1.0,7.1各種儀器設備未處于良好備用（使用）狀態,0.2

,,7.2儀器故障未及時報修,0.1

,,7.3各種搶救儀器不能熟練掌握操作步驟,0.2

,,7.4各種儀器設備不能處理報警、故障,0.1

,,7.5各種儀器設備不清潔（表面、連接線、導線、血氧飽和度探頭、袖帶、管路等）,0.2

,,7.6儀器、設備未及時消毒、更換（呼吸機管路、潮化罐、超聲霧化器、吸氧潮化瓶等）未設有維修記錄本、使用記錄本，記錄不及時,0.2

8,護理1.0,8.1示正確、及時執行醫囑的各項護理（如吸氧、霧化、鼻飼、吸談、換藥、口護、尿、護、氣切護理等）,0.025

,,8.2眼瞼不閉合未有處理措施,0.025

,,8.3患者口唇干裂未護理,0.025

,,8.4躁動、昏迷、不能處理患者無安全措施,0.025

,,8.5約束帶臟、使用不當，無知情同意書,0.025

,,8.6未及時發現護理問題：1液體外滲，2輸液反應，3液體出入量不平衡，4輸液結束未及時更換等,0.025

,,8.7患者未保持良好的功能體位，如防止誤吸的體位、防止足下垂的體位等,0.025

,,8.8翻身時各種管路未給予保護,0.025

,,8.9翻身時傷口未給予保護,0.025

,,8.10未根據病情定時翻身、叩背、觀察受壓部位皮膚情況,0.025

,,8.11冷、熱護理不合理,0.025

,,8.12臥床患者褥瘡好發部位未有預防措施、無風險評估記錄單,0.025

,,8.13傷口敷料未包扎完好未及時處理,0.025

,,8.14傷口敷料（如氣管切開敷料）未及時更換,0.025

,,8.15傷口周圍未給予保護,0.025

,,8.16血壓計袖帶未縛于正確位置，松緊不適宜（肢體有輸液、動靜脈瘺、患肢等禁止時行測量血壓）,0.025

,,8.17血氧飽和度探頭未定時更換所夾部位,0.025

,,8.18靜脈注射速度與醫囑不符,0.025

,,8.19用過的注射器放在床頭柜上,0.025

,,8.20鼻飼速度過快,0.025

,,8.21鼻飼飲食溫度不適宜、鼻飼管內有鼻飼液積存，未及時沖洗,0.025

,,8.22吸痰不及時,0.025

,,8.23吸痰時違反無菌操作,0.025

,,8.24吸痰操作不正規,0.025

,,8.25氣管（氣切）插管氣囊壓力過高（低）,0.025

,,8.26氣管（氣切）插管未及時放氣囊,0.025

,,8.27氣管插管深度改變未有護理措施,0.025

序號,檢查內容,存在問題,分值

8,護理1.0,8.28氣切導管內套管未及時消毒,0.025

,,8.29人工鼻使用不正確,0.025

,,8.30輸液速度與病情、藥物說明不符、與記錄不符,0.025

,,8.31輸入需避光藥物未避光,0.025

,,8.32床旁未備手消液，手消液未注明開啟日期,0.025

,,8.33各項操作結束前后未及時洗手，有交叉感染可能,0.025

,,8.34病情變化未及時發現,0.025

,,8.35病情變化時未有處理措施,0.025

,,8.36未床頭交接班,0.025

,,8.37床頭交接班不清楚、有遺漏,0.025

,,8.38未掌握患者病情,0.025

,,8.39未掌握患者異常化驗,0.025

,,8.40配合醫生各項操作、搶救不到位,0.025

9,治療1.0,9.1未及時、正確的執行醫囑,0.15

,,9.2輸入藥物未合理安排（時間、順序、滴速、方法）,0.1

,,9.3輸液部位不規范，存在下肢靜脈穿刺、關節部位穿刺,0.15

,,9.4未掌握治療藥物的藥理作用,0.1

,,9.5未掌握治療藥物的目的,0.1

,,9.6未備齊急救藥品,0.1

,,9.7