Regarding basic nursing knowledge and nurse model operation

Author: Shanghai Kangji Source: Shanghai Kangji Medical Equipment Co., Ltd

What are the steps included in the nursing procedure?
The nursing procedure includes five steps: assessment, diagnosis, planning, implementation, and evaluation.

What are the methods for collecting data?
① Observation; ② Conversation; ③ Physical examination; ④ Refer to relevant materials.

What is the appropriate temperature and humidity for the ward?
(l) The temperature in the ward is generally maintained at 18-22 ℃. Newborns and elderly patients should maintain a room temperature of 22-24 ℃.
(2) The humidity in the ward is generally maintained between 50% and 60%.

What are the commonly used sleeping positions? Which patients are each applicable to?
(1) Lying supine position without pillow: suitable for patients who are unconscious or not awake under general anesthesia; Spinal anesthesia
Patients who are drunk or have undergone spinal cord puncture.
(2) Middle concave position: suitable for shock patients.
(3) Knee bending supine position: suitable for patients undergoing abdominal examination or receiving catheterization or perineal flushing.
(4) Lateral position: suitable for patients undergoing enema, anal examination, and in conjunction with gastroscopy and colonoscopy; Patients receiving intramuscular injections in the buttocks.
(5) Semi seated position: suitable for patients with respiratory distress caused by cardiovascular and pulmonary diseases; Patients who have undergone chest, abdominal, or pelvic surgery or have inflammation; Patients who have undergone certain facial and neck surgeries; Patients with weak physical constitution during the recovery period.
(6) End sitting position: suitable for patients with heart failure, pericardial effusion, and bronchial asthma attacks.
(7) Prone position: suitable for patients undergoing lumbar and back examinations or in conjunction with pancreatic and biliary imaging examinations; Patients who have undergone spinal surgery or have wounds on the waist, back, or buttocks and cannot lie flat or sideways; Patients with abdominal pain caused by bloating in the gastrointestinal tract.
(8) Head down, foot up: suitable for patients with pulmonary secretion drainage; Patients undergoing duodenal drainage surgery; Patients with premature rupture of membranes during pregnancy; Patients with traction of the calcaneus or tibial tuberosity.
(9) Head high and foot low: suitable for patients with cervical fractures undergoing skull traction; Patients after cranial surgery.
(10) Knee chest position: suitable for patients undergoing anal, rectal, and sigmoid colonoscopy examination and treatment; Patients who require correction of fetal malposition or uterine retroversion; Promote postpartum uterine recovery.
(11) Stone cutting position: suitable for patients undergoing examination, treatment, or surgery in the perineum and anus, and for postpartum women.

What are the precautions for special patients when changing their sleeping position?
(1) For those who have various catheters or infusion devices, they should first place the catheters properly, turn them over, and carefully check to keep the catheters unobstructed.
(2) For those who have cervical or skull traction, do not relax the traction when turning over, and keep the head, neck, and torso in the same horizontal position when turning over; After turning over, pay attention to whether the traction direction, position, and traction force are correct.
(3) For patients undergoing cranial surgery, they should be placed in a healthy lateral or supine position. When turning over, they should be careful not to vigorously flip their head to avoid causing brain herniation, compression of the brainstem, and sudden death of the patient.
(4) Gypsum fixers should pay attention to the location of the affected area and the blood supply of the local 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 has fallen off. If the dressing is soaked with secretions, it should be replaced and fixed properly before turning over. After turning over, be careful not to compress the wound.

6. What are the precautions when using restraints?
(1) Strictly grasp the application indications and pay attention to maintaining the patient's self-esteem.
(2) Explain the purpose, operating points, and precautions of using restraints to patients and their families to gain understanding and cooperation.
(3) The restraint device can only be used for a short period of time and should be released regularly to assist patients in changing positions frequently.
(4) When in use, the limbs are in a functional position; Underneath the restraint band, a cushion should be placed with appropriate elasticity; Closely observe the skin color of the constrained area and perform local massage if necessary to promote blood circulation.
(5) Record the reasons for using restraints, time, observation results, nursing measures, and the time of releasing restraints.

What are the contents of pain assessment?
① The area of pain; ② The duration of pain; ③ The nature of pain; ④ The degree of pain; ⑤ The expression of pain; ⑥ Factors affecting pain; ⑦ The impact of pain on patients, whether there are accompanying symptoms, etc.

What are the commonly used pain assessment tools?
① Digital evaluation method; ② Textual descriptive evaluation method; ③ Visual simulation evaluation method; ④ Facial expression measurement chart.

How to use 0-5 word description method to evaluate pain?
Level 0 without pain.
Grade 1 mild pain: tolerable, able to live and sleep normally.
Grade 2 moderate pain: Mild disturbance to sleep, requiring painkillers.
Level 3 Severe pain: disrupts sleep and requires anesthesia and painkillers.
Grade 4 severe pain: significant disturbance to sleep, accompanied by other symptoms.
Level 5 intolerable: severe disturbance to sleep, accompanied by other symptoms or passive position.

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10. Briefly describe the grading of muscle strength.
Level 0: * Paralysis, loss of muscle strength *.
Level 1: Slight muscle contraction but no limb movement is visible.
Level 2: Moveable but unable to lift.
Level 3: The limbs can lift but cannot resist resistance.
Level 4: Able to perform resistance exercises, but with weakened muscle strength.
Level 5: Normal muscle strength.

What are the stages of pressure ulcers? Describe the reasons for its occurrence.
According to its severity and depth of invasion, it can be divided into four stages: ① period of congestion and redness; ② Inflammatory infiltration period; ③ Mild ulcer stage; ④ Necrotic ulcer stage.
Reason for occurrence:
(1) Local long-term exposure to pressure, friction, or shear forces.
(2) Locally frequently exposed to moisture or excrement.
(3) Improper use of plaster bandages and splints.
(4) Systemic malnutrition or edema.

12. Briefly describe the grading of the body's activity ability.
0 degrees: completely independent and free to move around.
1 degree: requires the use of equipment or devices (such as crutches, wheelchairs).
Degree 2: Requires help, supervision, and education from others.
3 degrees: Both assistance from people and equipment and tools are needed.
4 degrees: * Cannot be independent and cannot participate in activities.

What are the precautions for measuring blood pressure?
(1) Regularly check and calibrate blood pressure monitors.
(2) For those who need to closely monitor their blood pressure, they should adhere to the four principles of time, location, position, and blood pressure monitor.
(3) If blood pressure is found to be inaudible or abnormal, it should be retested.
(4) Pay attention to the errors in blood pressure measurement caused by factors such as pressure measuring devices (blood pressure monitors, stethoscopes), measurers, subjects, and measurement environments to ensure the accuracy of blood pressure measurement.

What are the effects of the cuff being too loose or too tight when measuring blood pressure?
(1) Loosening the cuff can cause the airbag to form a spherical shape, narrowing the effective measurement area and resulting in higher blood pressure readings.
(2) Tight cuff wrapping can cause blood vessels to be compressed before inflation, resulting in lower blood pressure readings.

15. How to measure pulse rate for patients with short pulse?
To measure the pulse rate of patients with short pulse, two people should measure it simultaneously, one listening to the heart rate and the other measuring the pulse rate. Both people should start at the same time, and the person listening to the heart rate should give the "start" and "stop" commands, timing for 1 minute.

16. What is tidal breathing?
Tidal breathing refers to the process of breathing from shallow slow to deep fast, and then from deep fast to shallow slow again, followed by a period of breathing pause (5 ^ -3 seconds), and then repeating the above periodic breathing, resembling the ebb and flow of the tide.

What are the taboo areas for cold therapy? Why?
(1) Behind the pillow, earlobe, and scrotum: to prevent frostbite.
(2) Pre cardiac area: to prevent reflex bradycardia, atrial fibrillation, or atrioventricular block.
(3) Abdominal: To prevent diarrhea 0
(4) Plantar area: to prevent reflexive peripheral vascular constriction that affects heat dissipation or causes transient coronary artery constriction.

What are the contraindications for thermal therapy?
(1) Acute abdominal pain without clear diagnosis.
(2) Infection in the dangerous triangle area of the face.
(3) Bleeding from various organs.
(4) Early stage of soft tissue injury or sprain (within 48 hours).
(5) Skin eczema.
(6) Acute inflammatory reactions, such as periodontitis, otitis media, and conjunctivitis.
(7) Metal graft site.
(8) Malignant lesion site.

What are the contents that should be evaluated before nasal feeding?
(1) Whether the gastric tube is in the stomach and unobstructed, and only after confirming that the gastric tube is in the stomach can it be injected.
(2) If there is no gastric retention, and the extracted gastric contents are greater than 100ml, nasal feeding should be suspended.

What is the 24-hour urine output of a normal person? What are polyuria, oliguria, and anuria?
The normal 24-hour urine output is about 1000-2000ml, with an average of 1500ml
Polyuria: Refers to a 24-hour urine output that frequently exceeds 2500ml
Oliguria: refers to a 24-hour urine output of less than 400ml or an hourly urine output of less than 17ml
Anuria: also known as urinary obstruction, refers to a condition where the urine output is less than 100ml within 24 hours or there is no urine within 12 hours.

21. Briefly describe the collection method of 24-hour urine samples.
(1) At 7am, empty the bladder and collect all subsequent urine in a large clean container (such as clean sputum). By 7am the next day, drain the last batch of urine into the container, measure the total amount, and record it on the laboratory report.
(2) Mix all the specimens evenly, take out about 20ml of the specimen, and place it in a clean and dry container for testing as soon as possible.
(3) Some special tests require the addition of preservatives depending on the specific situation.

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 in the urine, and when there are a high amount of red blood cells, it appears as flesh washing water.
(2) Hemoglobinuria: A large number of red blood cells are destroyed in the blood vessels, presenting a dark brown or soy sauce like color.
(3) Bilirubinuria: the urine is dark yellow or yellowish brown, and the foam is yellow after shaking the urine.
(4) Chyluria: Urine contains lymphatic fluid, which is milky white in color.
(5) Pyuria: Urine contains pus, which is white, flocculent, and turbid, and can be seen to contain
Puss.

What are the nursing measures for acute urinary retention?
(1) Reason for termination.
(2) Promote urination: For postoperative urinary retention patients, induce urination, and if necessary, perform sterile catheterization, and take care of the urinary catheter and urethral opening. For those who undergo suprapubic bladder puncture or suprapubic bladder fistula surgery, take care of the bladder fistula tube and keep it unobstructed.
(3) Avoid bladder bleeding: The amount of urine discharged at once should not exceed 1000ml to avoid bladder bleeding.

What are the key points of skin care for patients with urinary incontinence?
(1) Keep the bed sheets clean, flat, and dry.
(2) Timely clean the skin of the perineum, keep it clean and dry, and apply skin protectants if necessary.
(3) According to the condition, corresponding protective measures can be taken. Male patients can use urinary condoms, while female patients can use urine pads, urine collectors, or indwelling catheters.

What principles should be followed when administering medication?
(1) Accurately administer medication according to medical orders: strictly follow medical orders, and only administer medication after understanding any suspicious orders to avoid blind execution.
(2) Strictly implement the "three checks and seven pairs" system.
(3) Safe and correct administration: Reasonably control the administration time and method, and distribute and use the medication in a timely manner after preparation. Explain and provide medication guidance before administration. Understand the allergy history before using drugs that are prone to allergic reactions.
(4) Observation of medication reactions: drug efficacy, adverse reactions, changes in patient condition, dependence on drugs, emotional reactions, etc.

What are the precautions to be taken when taking oral medication?
(1) Medications that need to be swallowed are usually taken with warm water at 40-60 ℃, and should not be taken with tea water.
(2) Medications that have a corrosive effect on teeth, such as acids and iron, should be taken through a straw and rinsed with mouth to protect teeth.
(3) Extended release tablets, enteric coated tablets, and capsules should not be chewed when swallowed.
(4) Sublingual lozenges should be placed under the tongue or between the buccal membrane and teeth until they dissolve.
(5) Antibiotics and sulfonamide drugs should be taken on time to ensure effective blood drug concentrations.
(6) It is not advisable to drink water immediately after taking medication that soothes the respiratory mucosa. The information is from the ICU Nursing Home public account. Please stay tuned.
(7) Some sulfonamide drugs are excreted through the kidneys, and when urine is scarce, they are prone to crystallize and block the renal tubules. After taking the medication, it is important to drink plenty of water.
(8) In general, stomach strengthening drugs should be taken before meals, digestive aids and drugs that stimulate the gastric mucosa should be taken after meals, and hypnotic drugs should be taken before bedtime.

What are the precautions for oral iron treatment?
(1) To reduce gastrointestinal reactions, it can be taken after or during meals, starting from a small dose and gradually increasing to a sufficient amount.
(2) Liquid iron can darken teeth and can be taken with a straw or dropper.
(3) Iron supplements can be taken in combination with vitamin C and fruit juice to facilitate absorption; Do not consume with foods that inhibit iron absorption.
(4) After taking iron supplements, the stool turns black or appears tarry. After stopping the medication and recovering, the reason should be explained to the patient to eliminate any concerns.
(5) Take medication according to dosage and course of treatment, and regularly review relevant laboratory tests.

What are the commonly used oral care solutions? What are their respective functions?
Clean the mouth with physiological saline solution to prevent infection; 1% -3% hydrogen peroxide solution for corrosion and odor prevention, suitable for oral infections with ulceration and necrotic tissue
1% to 4% sodium bicarbonate solution alkaline solution, suitable for fungal infections
0.02% Chlorhexidine solution cleanses the mouth and has broad-spectrum antibacterial properties
0.02% Furacillin solution cleanses the mouth and has broad-spectrum antibacterial properties
0.1% acetic acid solution is suitable for Pseudomonas aeruginosa infection
2% to 3% boric acid solution as an acidic preservative, with antibacterial properties
0.08% metronidazole solution suitable for anaerobic bacterial infections

What are the types of oxygen therapy? What types of patients are they suitable for?
(1) Low concentration oxygen therapy: Oxygen concentration<40%. Applicable to patients with hypoxemia and carbon dioxide storage, such as chronic obstructive pulmonary disease.
(2) Moderate concentration oxygen therapy: Oxygen inhalation concentration of 40% -60% 0 is suitable for patients with significant ventilation/perfusion imbalance or significant diffusion disorders, such as pulmonary edema, myocardial infarction
Shock, etc.
(3) High concentration oxygen therapy: Oxygen concentration>60%. Suitable for patients with simple hypoxia without carbon dioxide storage, such as adult respiratory distress syndrome and life support stage after cardiopulmonary resuscitation.
(4) Hyperbaric oxygen therapy: refers to administering 100% oxygen inhalation at a pressure of 2-3kg/square centimeter 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 causes.
(2) Keep the respiratory tract unobstructed.
(3) Choose the appropriate oxygen therapy method.
(4) Pay attention to humidification and heating.
(5) Regularly replace and disinfect to prevent contamination and blockage of the conduit.
(6) Evaluation of Oxygen Therapy Effectiveness.
(7) Prevent explosions and fires.

How to convert oxygen concentration and oxygen flow rate?
Oxygen concentration (%)=21+4 * Oxygen flow rate (L/min)

32. What are the precautions for oxygen atomization inhalation?
(1) Correctly use the oxygen supply device, pay attention to oxygen safety, and do not hold water in the oxygen humidification bottle to avoid dilution of the medication and affect the therapeutic effect.
(2) During nebulization, instruct the patient to inhale deeply through the mouth and hold their breath for 1-2 seconds, then exhale through the nose with an oxygen flow rate of 6-8 L/min
(3) Pay attention to the patient's sputum discharge and assist in cleaning their mouth after nebulization.

What are the clinical manifestations of penicillin induced anaphylactic shock?
(1) Symptoms of respiratory obstruction: manifested as chest tightness, shortness of breath, and a feeling of impending death.
(2) Symptoms of circulatory failure: manifested as pale complexion, cold sweat, palpitations, weak pulse, decreased blood pressure, restlessness, etc.
(3) Central nervous system symptoms: manifested as dizziness, blurred vision, numbness in the face and limbs, loss of consciousness, convulsions, urinary and fecal incontinence, etc.
(4) Other allergic reactions may include urticaria, nausea, vomiting, abdominal pain, and diarrhea.

34. Briefly describe the emergency nursing measures for penicillin induced shock.
(1) Immediately stop the medication and let the patient lie flat.
(2) Immediately inject 0.1% adrenaline hydrochloride subcutaneously. 0.5—1ml， Patients are advised to reduce their expenses. If the symptoms do not improve, 0.5ml of the drug can be injected subcutaneously or intravenously every 30 minutes
(3) Oxygen inhalation. When breathing is inhibited, mouth to mouth resuscitation should be performed immediately, and respiratory stimulants should be injected intramuscularly. When laryngeal edema affects breathing, tracheal intubation or tracheotomy should be prepared immediately.
(4) Anti allergic
(5) Correct acidosis and follow medical advice to administer antihistamines.
(6) If sudden cardiac arrest occurs, perform cardiopulmonary resuscitation immediately.
(7) Closely observe vital signs, urine output, and other changes in the condition, pay attention to keeping warm, and
Keep a dynamic record of the patient's condition. Patients should not be moved before they are out of danger.

How to classify venipuncture tools?
According to the type of blood vessels used for catheterization, it can be divided into peripheral venous catheters and central venous catheters. According to the length of the catheter, it can be divided into short catheter, medium length catheter, and long catheter.

How to flush and seal a venous catheter?
(1) Tube flushing method: The flushing solution is usually physiological saline, and a pulse flushing method is used. The peripheral indwelling needle can be flushed with a 5ml syringe; The PICC catheter should be flushed with a syringe of 10ml or more. The minimum amount of flushing fluid should be twice the capacity of the conduit and additional devices.
(2) Sealing method: ① Steel needle method: Leave the needle tip slightly inside the heparin cap, and when 0.5-1ml of sealing solution is left by pulse injection, push the sealing solution while pulling out the needle (pushing speed is greater than pulling speed), ensuring that the catheter is filled with sealing solution and free of medication or blood inside the catheter. ② Needle free connector method: After flushing the tube, before removing the syringe, place the small clip as close as possible to the puncture point. After clamping, remove the syringe with the small clip.

What are the clinical manifestations of common infusion reactions?
(1) Fever reaction: It often occurs several minutes to one hour after factory infusion. Manifested as chills, shivering, and fever. Mild cases have a body temperature of around 38 ℃, and can recover to normal within a few hours after stopping infusion; Severe cases may start with chills, followed by high fever, with a body temperature of over 40 ℃, accompanied by systemic symptoms such as headache, nausea, vomiting, and pulse rate.
(2) Acute pulmonary edema: the patient suddenly has dyspnea, chest tightness, cough, and pink foam like sputum. In severe cases, sputum can gush from the mouth and nose. Auscultation shows that the lungs are filled with moist gong sounds, and the heart rate is fast and irregular.
(3) Venoitis: A linear red line appears along the vein, with local tissue turning red, swollen, burning, and painful, sometimes accompanied by systemic symptoms such as chills and fever.
(4) Air embolism: The patient experiences abnormal chest discomfort or pain behind the sternum Immediately, there was difficulty breathing and severe discomfort, accompanied by a feeling of impending death. Auscultation of the precordial area can result in a loud and sustained "water bubble sound".

38. Briefly describe the causes and treatment measures of acute pulmonary edema during infusion.
reason:
(1) The infusion speed is too fast, and too much fluid is infused in a short period of time, causing a sharp increase in circulating blood volume and resulting in excessive cardiac load.
(2) The patient had pre-existing heart and lung dysfunction.
Handling measures:
(1) Immediately stop the infusion and notify the doctor for emergency treatment. If the condition permits, the patient can sit upright with legs hanging down to reduce venous reflux in the lower limbs and alleviate the burden on the heart.
(2) Inject high flow oxygen into the humidification bottle, with a typical oxygen flow rate of 6-8 L/min. At the same time, add 20% -30% ethanol solution to the bottle.
(3) Administer sedatives, asthma relievers, cardiac stimulants, diuretics, and vasodilators according to medical advice.
(4) If necessary, perform quadriplegic wheel binding. Apply appropriate pressure with a rubber tourniquet or sphygmomanometer cuff to block venous blood flow. Relaxing the tourniquet on one limb every 5-10 minutes can effectively reduce venous return blood volume. After the symptoms subside, gradually remove the tourniquet.

What position should patients adopt when air embolism occurs during infusion? Why?
The patient should be placed in a left lateral position and kept head down and feet high. This position is conducive to the gas floating to the right ventricular tip, avoiding the pulmonary artery population. With the heart contracting and relaxing, the air will be mixed into foam, which will enter the pulmonary artery in small amounts and gradually be absorbed.

What are the precautions for using mannitol?
(l) Intramuscular or subcutaneous injection is strictly prohibited to avoid subcutaneous edema or tissue necrosis caused by drug leakage.
(2) Cannot be mixed with other drugs for intravenous infusion
(3) When intravenous infusion, it is advisable to use a large needle, and 250ml of liquid should be dripped intravenously within 20-30 minutes.
(4) During the application of dehydrating agents, the volume, blood pressure, pulse, and respiration should be closely observed and recorded.
(5) It can rapidly increase blood volume and is contraindicated for patients with heart failure and acute pulmonary edema.

41. According to the type of antigen on the red blood cell membrane What are the types of blood types?
(1) Type A: Individuals with only A antigen on their red blood cell membrane.
(2) Type B: Individuals with only B antigen on the red blood cell membrane.
(3) AB type: those with two antigens, A and B, on the red blood cell membrane.
(4) Type O: Individuals with neither A nor B antigens present on the red blood cell membrane.

What are the precautions for component blood transfusion?
(1) Some components of blood, such as white blood cells, platelets, etc. (excluding red blood cells), have a short survival period and fresh blood is recommended. They must be transfused into the human body within 24 hours (counting from the time of blood collection).
(2) Except for plasma and albumin preparations, cross matching tests are required for all other components of blood before transfusion.
(3) Administer anti allergic medication according to medical advice before blood transfusion.
(4) If the patient needs to receive whole blood while receiving component blood transfusion Then, component blood should be transfused first, followed by whole blood to ensure the effectiveness of the component blood.

What are the common transfusion reactions?
① Fever reaction; ② Allergic reactions; ③ Hemolysis reaction; ④ Massive transfusion reactions;
⑤ Bacterial contamination reaction; ⑥ Disease infection, etc.

How to deal with allergic reactions during blood transfusion?
(1) Mild allergic reaction, slow down blood transfusion speed, and administer anti allergic medication.
(2) Moderate to severe allergic reactions require immediate cessation of blood transfusion and subcutaneous injection of 0.1% adrenaline. 0.5—1ml， Intravenous injection of anti allergic drugs such as dexamethasone.
(3) Patients with breathing difficulties should be given oxygen inhalation, and severe laryngeal edema should be treated with tracheotomy.
(4) Patients with circulatory failure should receive anti shock treatment.

What are the reasons for hemolytic reactions during blood transfusion? How to handle it?
reason:
(1) Entered atypical blood.
(2) Entered spoiled blood.
(3) Hemolysis caused by Rh factor.
Handling measures:
(1) Immediately stop the blood transfusion and notify the doctor.
(2) Administer oxygen inhalation, establish venous access, and follow medical advice to administer vasopressors or other medications for treatment.
(3) Send residual blood, patient blood samples, and urine samples to the laboratory for testing.
(4) Close the waist on both sides and apply hot water to the kidney area with a hot water bag to relieve tubular spasm and protect the kidneys.
(5) Alkalinization of urine: intravenous injection of sodium bicarbonate solution.
(6) Closely observe vital signs and urine volume, insert a catheter, measure hourly urine volume, and keep records.
(7) If shock symptoms occur, anti shock treatment should be performed.
(8) Psychological care: Comfort patients and eliminate their tension and fear.

What are the main contents of disease observation?
(1) General observations: development and body shape, diet and nutritional status, facial features and expressions, posture, posture and gait, skin and mucous membranes, etc.
(2) Observation of vital signs.
(3) Observation of the state of consciousness.
(4) Observation of pupils.
(5) Observation of psychological state.
(6) Observation of special examinations or drug treatments.
(7) Observation of secretions, excreta, and vomit.

How to determine different degrees of consciousness disorders?
(1) Sleepiness: The most mild form of consciousness disorder. The patient is in a continuous sleep state, but can be awakened by speech or mild stimulation. After waking up, they can answer questions correctly, simply, and slowly, but their response is slow. After stopping the stimulation, they quickly fall asleep again.
(2) Blurred consciousness: Its degree is deeper than drowsiness. Manifested as disorientation, incoherent thinking and language, and may have delusions, hallucinations, restlessness, delirium, or mental confusion.
(3) Sleepiness: The patient is in a state of deep sleep and is not easily awakened. But it can be awakened by strong stimuli such as compressing the orbital nerve and shaking the body. After waking up, the answer is vague or irrelevant, and after stopping the stimulation, it enters a deep sleep state again.
(4) Shallow coma: Loss of consciousness, lack of autonomous activity, no response to light and sound stimuli, and defensive responses such as painful expressions or limb withdrawal to pain stimuli.
(5) Deep coma: loss of consciousness and no response to various stimuli.

48. How to determine pupil size?
Under natural light, the pupil diameter is 2-5mm, with an average of 3-4mm
Under pathological conditions, a pupil diameter less than 2mm is considered pupil constriction, while a diameter less than Imm is considered needle like pupil. Pupil diameter greater than 5mm is considered dilated.

What are the clinical manifestations of deep vein thrombosis in the lower limbs? How to prevent it?
clinical manifestation:
(1) Swelling of the affected limb accompanied by elevated skin temperature.
(2) Localized severe pain or tenderness.
(3) Humans sign positive, excessive dorsiflexion test can cause severe leg pain.
(4) Superficial vein dilation.
Preventive measures:
(1) Moderate exercise promotes venous return. Long term bed rest and immobilization patients should strengthen bed exercise; Early mobilization of postoperative patients; For individuals with hypercoagulable blood, prophylactic use of anticoagulant drugs is recommended.
(2) Protecting veins: For long-term intravenous infusion patients, efforts should be made to protect veins and avoid repeated punctures at the same site. Try to avoid intravenous infusion in the lower limbs.
(3) Quit smoking.
(4) Eat a low-fat, high fiber diet to maintain smooth bowel movements.

What are the basic principles that nursing document recording should follow?
(1) Timely: Nursing records must be timely, without delay or advance, and must not be missed or incorrectly recorded to ensure the timeliness of the records. If the rescue fails to be recorded in a timely manner, it should be recorded truthfully within 6 hours after the rescue is completed, and the time of completion of the rescue and the time of supplementation should be indicated.
(2) Accuracy: The content is true and accurate, and the recorded time should be the actual time of administration, treatment, and care.
(3) Complete: The eyebrow and page numbers must be filled in completely. Record continuously without leaving any blank spaces. Sign the full name after each record.
(4) Brief: Emphasize key points, be concise, and fluent, using medical terminology and abbreviations of *.
(5) Clear: Write with red and blue pens as required, with clear handwriting, neat fonts, and no alterations, cutting, or misuse of simplified characters.

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