Validity period for referral to treatment room

06.09.2019

3. General documentation for the treatment room

Conclusion

Literature

Introduction

For this purpose, nursing documentation and standards are being developed and implemented to promote full analysis patient problems, ways to solve them, allowing to assess the quality of nursing care. Along with this, programs for assessing the quality of nursing care have been developed, as well as an end result model with the ability economic stimulation work of a nurse. Functional responsibilities nurse treatment room is: Proper organization of the work of the room to carry out therapeutic and diagnostic measures, according to the profile of the department. Immediately notify the doctor about complications associated with the procedures. Providing pre-medical care medical care. Strict adherence to asepsis, antiseptics, infection safety standards, OST 42-21-2-85 “Sterilization and disinfection of products medical purposes" Strict implementation of measures to prevent serum hepatitis and HIV infection. Compliance with the sanitary and epidemiological regime of the office in accordance with current orders.

Timely replenishment of the cabinet with medicines and instruments. Ensuring proper storage of medications, serums, monitoring expiration dates. Accurate documentation. Compliance with safety regulations. Improve qualifications and professional skills.

1. Functions of a treatment room nurse

I. Carrying out diagnostic and treatment measures:

Administration of medications and carrying out therapeutic procedures in accordance with the regulation of the nurse’s activities;

Taking blood from a vein for diagnostic studies;

Assisting a doctor with:

a) carrying out manipulations during in serious condition sick;

b) determination of blood group and Rh factor;

c) testing a new drug.

II. Office work. Logging:

Appointments;

Accounting for the work of the treatment room;

Accounting for intravenous infusions and drips;

Accounting for intramuscular, subcutaneous injections and antibiotics;

Delivery of bixes to the central sterilization room;

Registration of general cleaning;

Registration of patients who have had hepatitis;

Complications associated with medical procedures.

III. Relief of complications associated with medical procedures by notifying the doctor.

IV. Organization of work of junior medical staff.

V. Participation in the preparation of a reserve of nurses in the treatment room.

2. Treatment room documentation

In order to comply with the sanitary and epidemiological regime, an order was put into effect, which is used in healthcare institutions; the order contains the following provisions:

Order of the USSR Ministry of Health dated June 10, 1985 No. 770 on the implementation of the industry standard OST 42-21-2-85 sterilization and disinfection of medical devices. Methods, means and regimes (together with the industry standard, approved by the USSR Ministry of Health on 06/07/1985)

GOST 42-21-2-85 “Sterilization and disinfection of medical devices. Methods, means, regimes."

Guide R.3.1.683-98 “Use of ultraviolet bactericidal radiation for disinfection of air and surfaces in premises);

Order of the USSR Ministry of Health No. 408 dated June 12, 1989. “On measures to reduce the incidence of viral hepatitis in the country”

Order of the Ministry of Health and the Ministry of Health of the Russian Federation No. 170 of August 16, 1994 “On measures to improve the prevention and treatment of HIV infection in Russia.”

SanPiN 2.1.3.1375-03 dated June 6, 2003 “Hygienic requirements for the placement, equipment and operation of hospitals, type. homes and other medical hospitals."

Order of the Federal State Institution TsGSEN RME No. 130/84 SE dated June 1, 2001 “On improving measures for the prevention of nosocomial infections in health care facilities of the republic.”

SanPin 2.1.5.980-99 “Rules for the collection, storage and disposal of healthcare facility waste.”

SP 3.1.958-00. “Prevention of viral hepatitis. General requirements towards epidemiological surveillance of viral hepatitis".

Order of the Ministry of Health and MP of the Russian Federation No. 170 of August 16, 1994 “On the introduction
preventive vaccinations against hepatitis B."

Order of the Ministry of Health of the Russian Federation No. 25 of January 1998 “On strengthening measures to prevent influenza and other acute respiratory infections.”

Regulatory documents regulating the accounting, storage and dispensing of medicines of various groups:

Order of the USSR Ministry of Health dated August 30, 1991. No. 245 “On consumption standards ethyl alcohol for healthcare, education and social welfare institutions.”

Order of the USSR Ministry of Health dated June 2, 1987 No. 747 “Instructions for recording medications and dressings. medical instruments"

Order of the USSR Ministry of Health No. 720 of July 31, 1978 “On improving medical care for patients with purulent - surgical diseases and strengthening measures to combat nosocomial infections”

Order of the USSR Ministry of Health dated 30.0891 No. 245 “On standards for the consumption of ethyl alcohol for healthcare, education and social security institutions”

Order of the USSR Ministry of Health dated June 2, 198. No. 747 “Instructions for recording medications, dressings, medical instruments”

Appendix No. 2 No. Approximate consumption rates of ethyl alcohol in departments of health care facilities"

All medications are divided into three groups: “A”, “B” and “General List”. According to the method of administration, medications are divided into: parenteral, internal and external.

Group “A” includes narcotic and poisonous drugs, which are stored by the head nurse in a metal safe under lock and key and fixed to the floor. On the back of the safe is the letter "A" in white on a black background and the word "VENENA" in black letters on a white background. On the left side wall there is an inscription “narcotic drugs”, on the right wall of the safe there is an inscription “poisonous”. On the inside wall of the safe door is a list of narcotic and poisonous agents, their highest daily and single doses.

All potent drugs belong to group “B” and are stored in locked cabinets with markings: on the back wall there is a red letter “B” on a white background and the word “HEROICA” in black on a white background. List “B” includes 14 groups of medications, determined by their mechanism of action:

1. Antibiotics

2. Sulfonamides

3. Some digitalis preparations

4. Analgesics

5. Antispasmodics

6. Hypotensive

7. Sedatives

8. Sleeping pills

9. Hormonal

10. Diuretics

11. Anticonvulsants

12. Antiarrhythmic

13. CNS stimulants

14. Stimulating the respiratory center.

The cabinets are arranged according to their mechanism of action and application. Internal funds separately from parenteral ones.

On a substantive quantitative basis they stand psychotropic drugs from list No. 3 - 16 items.

Medicines of the “general list” are stored in cabinets with the inscription inside: on a white background in black letters “ general list". Parenteral are stored separately from internal and external medicines arranged according to the mechanism of action.

3. General documentation for the treatment room

The treatment room should have:

1. Professional job description.

2.Orders, instructions letters from the Ministry of Health of the Russian Federation, State Sanitary and Epidemiological Supervision institutions, local administrations regulating the activities of the nurse in the treatment room.

3. List of documentation for the treatment room:

· Cabinet quartzing notebook.

· General cleaning notebook

· Notebook for recording azopyram and phenolphthalein samples.

· Logbook for monitoring the sterilization of instruments and soft equipment.

· Treatment room appointment log.

· Notebook for recording intravenous blood sampling for biochemical analysis, HbSAg, blood group and Rh factor.

· Notebook for recording intravenous blood sampling on RW.

· Notebook for recording intravenous blood sampling for HIV infection.

· Refrigerator temperature control notebook.

· Log book of prof. Vaccination.

· Hepatitis vaccination record book.

4. List of equipment and treatment room equipment.

5. List of workflow sequence.

6. List of medications required to provide emergency assistance.

7.List of medications, list of measures taken for anaphylactic shock.

8. List of medicines, expiration dates.

9. Instructions for storing medications.

10. Higher single doses of narcotic drugs.

11. Table of antidotes for drug poisoning.

12. Higher single and daily doses of potent and toxic drugs.

13. Incompatibility of drugs.

14. List of medicines stored in the refrigerator, the sequence of their placement.

15. A set of anti-epidemic measures for the prevention of HIV//AIDS, hepatitis in the treatment room.

16. Precautionary measures when working with disinfectants and detergents.

17. First aid for poisoning with disinfectants.

18. Sterilization methods.

Standards:

· Standard of equipment for the treatment room;

· Standard for equipping the treatment room with solid equipment

· Antibiotic dilution standard;

· Standard intramuscular injections;

· Subcutaneous injection standard;

· Standard intravenous injection;

· Standard for taking blood for biochemical testing;

· General cleaning standard;

· Routine cleaning standard;

· Standard for covering a sterile table;

· Standard for laying bixes;

· Standard for preparing a 10% original clarified bleach solution.

treatment room nurse document

Conclusion

In the treatment room of the health care facility, all prescriptions of the attending physicians are carried out. The office should be equipped with everything for carrying out various medical procedures: performing injections - subcutaneous, intramuscular, intravenous; taking blood from a vein for laboratory tests; providing emergency assistance in emergency situations.

The procedural nurse is responsible for: proper organization operation of the treatment room around the clock; For timely fulfillment of doctor’s orders for procedures; For compliance with the sanitary and epidemiological regime at your workplace, aseptic and antiseptic rules; For providing the office with the necessary number of tools during the day, medicines, solutions, sterile material for performing procedures; For compliance with the conditions and rules for storing medicines, equipment, tools, and office equipment; For high-quality maintenance of office documentation and making notes on procedures performed. For the proper organization of the work of the office nurse.

Literature

1. Agkatseva S. A. Teaching practical skills in the system of secondary medical education. Algorithms of manipulation in the activities of a nurse. Phoenix, 2006 – 168 p.

2. Fundamentals of nursing: Textbook Weber V.R., Chuvakov G.I., Lapotnikov V.A., etc. - M.: Medicine, 2001-496p.

3. Guide for the treatment room nurse. Chernova O.V. – Rostov n/d: Phoenix, 2006 – 15 p.

4. Handbook for treatment room nurses Grinenko A.Ya. WORD. 2005 - 20s.

Introduction

Conclusion
Literature

Introduction

To provide effective and qualified care to a sick person, a nurse must have perfect knowledge of the necessary amount of deep knowledge, skills, and practical skills, that is, be a professional in her field.
For this purpose, nursing documentation and standards are being developed and implemented to facilitate a complete analysis of the patient’s problems, ways to solve them, and to assess the quality of nursing care. Along with this, programs for assessing the quality of nursing care have been developed, as well as a model final result with the possibility of economic incentives for the work of nurses. The functional responsibilities of the nurse in the treatment room are: Proper organization of the work of the room to carry out therapeutic and diagnostic measures, according to the profile of the department. Immediately notify the doctor about complications associated with the procedures. Providing first-aid medical care. Strict adherence to asepsis, antiseptics, infection safety standards, OST 42-21-2-85 “Sterilization and disinfection of medical devices.” Strict implementation of measures to prevent serum hepatitis and HIV infection. Compliance with the sanitary and epidemiological regime of the office in accordance with current orders.
Timely replenishment of the cabinet with medicines and instruments. Ensuring proper storage of medications, serums, monitoring expiration dates. Accurate documentation. Compliance with safety regulations. Improve qualifications and professional skills.

1. Functions of a treatment room nurse

I. Carrying out diagnostic and treatment measures:
administering medications and carrying out therapeutic procedures in accordance with the regulation of the nurse’s activities;
drawing blood from a vein for diagnostic studies;
assisting a doctor with:
a) carrying out manipulations in severe condition of the patient;
b) determination of blood group and Rh factor;
c) testing a new drug.
II. Office work. Logging:
appointments;
accounting for the work of the treatment room;
accounting for intravenous infusions and drips;
accounting for intramuscular, subcutaneous injections and antibiotics;
delivery of bixes to the central sterilization room;
registration of general cleaning;
registration of patients who have had hepatitis;
complications associated with medical procedures.
III. Relief of complications associated with medical procedures by notifying the doctor.
IV. Organization of work of junior medical staff.
V. Participation in the preparation of a reserve of nurses in the treatment room.

2. Treatment room documentation

In order to comply with the sanitary and epidemiological regime, an order was put into effect, which is used in healthcare institutions; the order contains the following provisions:
Order of the USSR Ministry of Health dated June 10, 1985 No. 770 on the implementation of the industry standard OST 42-21-2-85 sterilization and disinfection of medical products. Methods, means and regimes (together with the industry standard, approved by the USSR Ministry of Health on 06/07/1985)
- GOST 42-21-2-85 “Sterilization and disinfection of medical products. Methods, means, regimes."
- Guide R.3.1.683-98 “Use of ultraviolet bactericidal radiation for disinfection of air and surfaces in premises);
-Order of the USSR Ministry of Health No. 408 dated June 12, 1989. “On measures to reduce the incidence of viral hepatitis in the country”
- Order of the Ministry of Health and the Ministry of Health of the Russian Federation No. 170 of August 16, 1994 “On measures to improve the prevention and treatment of HIV infection in Russia.”
- SanPiN 2.1.3.1375-03 dated June 6, 2003 “Hygienic requirements for the placement, equipment and operation of hospitals, type. homes and other medical hospitals."
- Order of the Federal State Institution TsGSEN RME No. 130/84 SE dated June 1, 2001 “On improving measures for the prevention of nosocomial infections in health care facilities of the republic.”
-SanPin 2.1.5.980-99 “Rules for the collection, storage and disposal of healthcare facility waste.”
-SP 3.1.958-00. “Prevention of viral hepatitis. General requirements for epidemiological surveillance of viral hepatitis."
- Order of the Ministry of Health and MP of the Russian Federation No. 170 of August 16, 1994 “On the introduction of preventive vaccinations against hepatitis B.”
- Order of the Ministry of Health of the Russian Federation No. 25 of January 1998 “On strengthening measures to prevent influenza and other acute respiratory infections.”
Regulatory documents regulating the accounting, storage and dispensing of medicines of various groups:
Order of the USSR Ministry of Health dated August 30, 1991. No. 245 “On standards for the consumption of ethyl alcohol for healthcare, education and social security institutions.”
Order of the USSR Ministry of Health dated June 2, 1987 No. 747 “Instructions for recording medications and dressings. medical instruments"
Order of the Ministry of Health of the USSR No. 720 of July 31, 1978 “On improving medical care for patients with purulent - surgical diseases and strengthening measures to combat nosocomial infections”
Order of the USSR Ministry of Health dated 30.0891 No. 245 “On standards for the consumption of ethyl alcohol for healthcare, education and social security institutions”
Order of the USSR Ministry of Health dated June 2, 198. No. 747 “Instructions for recording medications, dressings, medical instruments”
Appendix No. 2 No. Approximate consumption rates of ethyl alcohol in departments of health care facilities"
All medications are divided into three groups: “A”, “B” and “General List”. According to the method of administration, medications are divided into: parenteral, internal and external.
Group “A” includes narcotic and poisonous drugs, which are stored by the head nurse in a metal safe under lock and key and fixed to the floor. On the back of the safe is the letter "A" in white on a black background and the word "VENENA" in black letters on a white background. On the left side wall there is an inscription “narcotic drugs”, on the right wall of the safe there is an inscription “poisonous”. On the inside wall of the safe door is a list of narcotic and poisonous drugs, their highest daily and single doses.
All potent drugs belong to group “B”, are stored in locked cabinets with markings: on the back wall there is a red letter “B” on a white background and the word “HEROICA” in black on a white background. List “B” includes 14 groups of medications, determined by their mechanism of action:
1. Antibiotics
2. Sulfonamides
3. Some digitalis preparations
4. Analgesics
5. Antispasmodics
6. Hypotensive
7. Sedatives
8. Sleeping pills
9. Hormonal
10. Diuretics
11. Anticonvulsants
12. Antiarrhythmic
13. CNS stimulants
14. Stimulating the respiratory center.
The cabinets are arranged according to their mechanism of action and application. Internal agents are separate from parenteral ones.
The substantively quantitative list includes psychotropic drugs from list No. 3 - 16 items.
Medicines of the “general list” are stored in cabinets with the inscription inside: “general list” in black letters on a white background. Parenteral medications are stored separately from internal and external medications, arranged according to their mechanism of action.

3. General documentation for the treatment room

The treatment room should have:
1. Professional job description.
2.Orders, instructions letters from the Ministry of Health of the Russian Federation, State Sanitary and Epidemiological Supervision institutions, local administrations regulating the activities of the nurse in the treatment room.
3. List of documentation for the treatment room:
· Cabinet quartzing notebook.
· General cleaning notebook
· Notebook for recording azopyram and phenolphthalein samples.
· Logbook for monitoring the sterilization of instruments and soft equipment.
· Treatment room appointment log.
· Notebook for recording intravenous blood sampling for biochemical analysis, HbSAg, blood group and Rh factor.
· Notebook for recording intravenous blood sampling on RW.
· Notebook for recording intravenous blood sampling for HIV infection.
· Refrigerator temperature control notebook.
· Log book of prof. Vaccination.
· Hepatitis vaccination record book.
4. List of equipment and treatment room equipment.
5. List of workflow sequence.
6. List of medications required to provide emergency assistance.
7.List of medications, list of measures taken for anaphylactic shock.
8. List of medicines, expiration dates.
9. Instructions for storing medications.
10. Higher single doses of narcotic drugs.
11. Table of antidotes for drug poisoning.
12. Higher single and daily doses of potent and toxic drugs.
13. Incompatibility of drugs.
14. List of medicines stored in the refrigerator, the sequence of their placement.
15. A set of anti-epidemic measures for the prevention of HIV//AIDS, hepatitis in the treatment room.
16. Precautionary measures when working with disinfectants and detergents.
17. First aid for poisoning with disinfectants.
18. Sterilization methods.
Standards:
· Standard of equipment for the treatment room;
· Standard for equipping the treatment room with solid equipment
· Antibiotic dilution standard;
· Standard for intramuscular injections;
· Subcutaneous injection standard;
· Standard intravenous injection;
· Standard for taking blood for biochemical testing;
· General cleaning standard;
· Routine cleaning standard;
· Standard for covering a sterile table;
· Standard for laying bixes;
· Standard for preparing a 10% original clarified bleach solution.
treatment room nurse document
Conclusion

The quality of medical care is determined, first of all, by the healthcare system as a whole and each of its branches separately. The functioning of the healthcare system is determined by legislative and regulatory documents.
In the treatment room of the health care facility, all prescriptions of the attending physicians are carried out. The office should be equipped with everything for carrying out various medical procedures: performing injections - subcutaneous, intramuscular, intravenous; taking blood from a vein for laboratory tests; providing emergency assistance in emergency situations.
The procedural nurse is responsible for: the correct organization of the work of the treatment room around the clock; For timely fulfillment of doctor’s orders for procedures; For compliance with the sanitary and epidemiological regime at your workplace, aseptic and antiseptic rules; For providing the office during the day with the necessary number of instruments, medications, solutions, sterile material for performing procedures; For compliance with the conditions and rules for storing medicines, equipment, tools, and office equipment; For high-quality maintenance of office documentation and making notes on procedures performed. For the proper organization of the work of the office nurse.

Literature

1. Agkatseva S. A. Teaching practical skills in the system of secondary medical education. Algorithms of manipulation in the activities of a nurse. Phoenix, 2006 – 168 p.
2. Fundamentals of Nursing: Tutorial Weber V.R., Chuvakov G.I., Lapotnikov V.A., et al. - M.: Medicine, 2001-496p.
3. Guide for the treatment room nurse. Chernova O.V. – Rostov n/d: Phoenix, 2006 – 15 p.
4. Handbook for nurses in the treatment room Grinenko A.Ya. WORD. 2005 - 20s.
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Introduction

1. Functions of a treatment room nurse

2. Treatment room documentation

3. General documentation for the treatment room

Conclusion

Literature

Introduction

For this purpose, nursing documentation and standards are being developed and implemented to facilitate a complete analysis of the patient’s problems, ways to solve them, and to assess the quality of nursing care. Along with this, programs have been developed to assess the quality of nursing care, as well as a model of the final result with the possibility of economic incentives for the work of nurses. The functional responsibilities of the nurse in the treatment room are: Proper organization of the work of the room to carry out therapeutic and diagnostic measures, according to the profile of the department. Immediately notify the doctor about complications associated with the procedures. Providing first-aid medical care. Strict adherence to asepsis, antiseptics, infection safety standards, OST 42-21-2-85 “Sterilization and disinfection of medical devices.” Strict implementation of measures to prevent serum hepatitis and HIV infection. Compliance with the sanitary and epidemiological regime of the office in accordance with current orders.

1. Functions of a treatment room nurse

I. Carrying out diagnostic and treatment measures:

Administration of medications and carrying out therapeutic procedures in accordance with the regulation of the nurse’s activities;

Taking blood from a vein for diagnostic studies;

Assisting a doctor with:

a) carrying out manipulations in severe condition of the patient;