操作

前准

备10

分

2．着装整洁，洗手，戴口罩

3．查看“管道记录本”，转抄至“执行单”      

4．用物准备并检查：治疗车上层：普通换药包1个、75%酒精、%碘伏、弯盘、清洁手套1副、不小于10cm×10cm透明贴膜1张、快速手消毒剂，治疗车下层放医疗垃圾桶、生活垃圾桶

2

2

5

用物缺一项扣分

5分

2．自我介绍

3. 说明更换贴膜的目的，询问患者是否需要如厕，取得患者的合作

1

1

操作

步骤

60分

2. 评估CVC情况（贴膜、穿刺点、局部皮肤、导管、接头），如紧急情况请及时处理，否则待本次操作结束再处理

3．去除旧敷料：

（1）去除透明敷料外胶带

（2）“0”度角平拉敷料（0度撕膜法）

（3）由外向内去除原有敷料、切忌将导管带出体外，手不可触及贴膜覆盖部位的皮肤

4. 再次评估穿刺点、局部皮肤和外露导管情况

5. 快速手消毒剂搓手

6. 打开换药包、分别倒入适量消毒液、投递无菌贴膜、戴手套、整理棉球备用 

7．去脂、消毒：左手持纱布覆盖在输液接头轻向上提起导管，右手持酒精棉球，避开穿刺点直径1cm处，顺时针去脂、消毒，范围：以穿刺点为中心直径15cm（大于贴膜的面积），(翻转导管)，再夹取第二、三个酒精棉球以同样的方法逆、顺时针消毒皮肤

8. 消毒：酒精完全待干后，取碘伏棉球一个，放平导管以穿刺点为中心顺时针消毒皮肤及导管、取第二、三个碘伏棉球以同样的方法逆、顺时针消毒皮肤及导管，范围：以穿刺点为中心直径15cm（或略小于酒精消毒面积），待干

9．将体外导管逆血管方向摆放弧形（S、L或U型），确认导管不会打折，并放置好导管

10.覆盖贴膜：

（1）单手持膜、以穿刺点为中心无张力垂放

（2）沿着导管走向塑形

（3）由中心向四周抚平

（4）撕除背贴

（5）再次塑形、抚平

（6）手轻放于贴膜上用手心加温3-5s

（7）一条胶带横向固定导管出贴膜处下缘、一条胶带蝶型交叉固定贴膜下缘，在记录胶带上标注，（标注内容如CVC： 10:20 李美），贴于透明敷料下缘

11．再次确认导管不会打折

12． 整理用物、脱手套、洗手、记录

6

1

3

2

2

1

4

10

10

2

2

2

2

2

2

2

2

1

2

导管移位扣6分

污染一处扣2分

消毒不规范一次扣3分

消毒不规范一次扣3分

无待干扣10分

指导要点10分

2. 告知患者保持敷料、接头清洁干燥，每日应观察穿刺点及周围皮肤的完整性

3. 无菌透明敷料应至少每7天更换一次，无菌纱布敷料应至少每2天更换一次；若穿刺部位发生渗液、渗血时应及时更换敷料；穿刺部位的敷料发生松动、污染等完整性受损时应立即更换

2

5

操作后评价5分

2. 语言亲切、沟通有效

3. 操作熟练、顺序准确

4. 无菌观念强

5. 用物按医疗垃圾分类处理原则处置

1

1

1

1

提问

10分

2．注意事项

(1) 将体外导管放置呈弯曲或弧形，以降低导管张力，避免导管移动

(2) 禁止将脱出的导管移入体内

(3) 使用碘伏消毒，一定完全待干后再覆盖敷料

(4) 应每班评估导管的功能，观察穿刺点及周围皮肤的完整性

(5) 无菌透明敷料应至少每7天更换一次，无菌纱布敷料应至少每2天更换一次；若穿刺部位发生渗液、渗血时应及时更换敷料；穿刺部位的敷料发生松动、污染等完整性受损时应立即更换。

3.应急处理

(1)导管脱出：如导管脱出≥3cm，先用透明贴膜加强固定，避免再次污染、脱出；护送至PICC专科门诊，由专科护士处理

（2）穿刺点感染：如红肿、疼痛，可使用碘伏棉球湿敷5-15分钟、再换药，密切观察，必要时增加换药频次，或使用湿性敷料换药

（3）导管相关性血流感染：可疑导管相关性血流感染时，应立即停止输液，暂时保留，遵医嘱分别从导管内与外周血抽血，同时送检，查血培养；若有脓液，应取脓性液体，取样前避免消毒皮肤，以免影响细菌的培养并记录                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        

5

  3