Eleventh, the direction of efforts in 20XX:

1, standardize the patient treatment execution process; Various treatment items of patients, such as intramuscular injection, intravenous drip, oral administration, atomized inhalation, enema, abdominal cavity irrigation and drainage, nasal feeding, blood sugar determination, blood sample collection and examination, etc. All of them are made into treatment cards, which are hung on the patient's bedside after examination, and the nurses check and implement them one by one at the patient's bedside. When the shift is over, the shift nurse can check and verify the implementation of the patients' various treatments again, and the head nurse can also check and assess the nurses when visiting the ward.

2. Refine the flow of patients with drug allergy: 1) Before injecting cephalosporin or penicillin, the doctor must prescribe a skin test of cephalosporin or penicillin or ampicillin. When doing skin tests, they must carry 1mg adrenaline and ask patients about their drug allergy history. If there were allergy messengers, they wouldn't do skin tests. 2) When the drug is stopped for more than 24 hours or the drug batch number or drug is changed, the allergy test must be done again, and the preparation of allergy test solution, intradermal injection dose and judgment result should be accurate; 3) When printing the infusion card and copying it to the treatment list, the negative skin test results recorded in writing must be checked when the doctor's advice is executed for the first time, so that the treatment list can be copied and the infusion card can be printed, and then the patient can be treated. 4) For patients with positive skin test of cephalosporin or penicillin, or patients with allergic history, nurses must do the following work: 1. Insert a notice board with positive skin test of cephalosporin or penicillin beside the patient's bed. Patients with allergic history should indicate positive penicillin for private prosecution. 2. Add a cephalosporin skin test or penicillin positive red paper before the temperature list; 3. On the whiteboard of the key work in the ward, the bed number and name of the cephalosporin skin test or penicillin positive patient should be marked; 4. Mark cephalosporin skin test or penicillin positive on the cover of patient's medical record folder with adhesive tape and red pen; 5. On the patient's temporary doctor's advice, indicate the positive result with a red pen after the doctor's advice; 6. In the execution list (infusion card, intramuscular injection list), the last line of the patient's treatment content should be written as cephalosporin skin test or penicillin positive; 7. From the day when the skin test result is positive, it will be notified in the dynamic report for nine times for three consecutive days. If the patient has a history of drug allergy, it will start from the day of admission. ; 8. The nurse in charge should inform the doctor in charge, patients and their families of the positive results.

3. Discuss and study the implementation process and matters needing attention of setting up the second-level nursing station, prepare to implement the second-level nursing station, reduce the time for nurses to go back and forth between the ward and the treatment room and the nursing station, and facilitate the care of nurses and patients: the multifunctional treatment vehicle used now can facilitate the work of nurses, and the treatment vehicle can be set as the second-level nursing station. The nurses in the ward are divided into three groups, each with one person. On the upper floor of the treatment cart, the liquid and basic treatment tray that patients need to input on the same day are placed, and all the items such as nutrition bag, intramuscular injection medicine, oral medicine and treatment are placed in the drawer, and the patient's treatment sheet, infusion card, nursing record sheet and medical record are placed next to them. First, the trial operation is carried out, gradually changing the concept of nurses and trying to change the busy situation of nurses in the treatment room. This plan needs the support of nursing department and scientific guidance.

4. This year, we will focus on strengthening nurses' on-the-job training, improving nurses' comprehensive working ability, and promoting reading notes and discussion reports in nurse training:

1) Make a 20XX nurse training plan.

2) Adjust and enrich the contents of nurse training, mainly from the aspects of nursing safety, emergency response ability, professional knowledge, core system, technical operation, nurse-patient communication and health education.

3) According to the qualifications and abilities of nurses, the nurses are trained in groups:

The goal of nurse training after graduation 1 year is to independently complete the work of group nurses in clinical nursing. Training emphasis: ① Consolidate professional ideas, strictly meet quality requirements, and strengthen quality training for nurses. ② According to the clinical practice, do three basic exercises well. ③ Clarify the procedures of clinical nursing and the responsibilities and processes of nurses in each class. ④ Learn the nursing theory and skills of general surgery specialty. ⑤ Learn to give health education to patients and implement holistic nursing. Training requirements for nurses who have graduated for 2-3 years: independently complete all the nursing work of the department, master the specialized nursing knowledge, master the management system and work requirements of general surgery, master the basic monitoring theory and technology of general surgery, independently complete common critical nursing work as required, cooperate with the monitoring and rescue of critical patients, and gradually reach the level of nurses.

Every two weeks, the head nurse puts forward nursing learning topics according to the difficult problems encountered in patient care in the department. All nurses consult materials, record study notes and get familiar with the contents. During the continuing education in the department, they discussed and asked two nurses to answer the questions raised by everyone. Every nurse has to ask questions, and the head nurse will ask questions about the contents of reading notes at the morning meeting, so that nurses can understand common nursing problems, core systems, workflow and emergencies through reading notes, and continue to strengthen them.

5. Enrich the contents of the nurses' regular meeting in the department: prepare to break the situation that the nurses' regular meeting has many notices, many arrangements, simple contents and low efficiency in the past, and divide the nursing regular meeting into several columns, which will be carried out in stages: ① analyze and discuss the nursing hidden dangers this month by using the nursing regular meeting, so that nurses can find out the existing problems and corrective measures themselves; (2) Discuss the implementation of various nursing work, exchange experiences among colleagues and learn from each other; (3) Communicate and coordinate, communicate with relevant personnel in the department, invite doctors to attend regular meetings, realize feedback, eliminate misunderstandings and effectively solve problems; Nurses communicate with each other, let nurses talk about the difficulties and difficulties in their work, and let the head nurse fully understand the work of nurses and solve existing problems; (4) praise and criticism, safety education; ⑤ Academic exchange, talk about learning experience.

6. Further refine the job responsibilities: refine the job responsibilities of nurses in each class, especially the continuity between classes, improve the loophole areas between classes, and ensure that every detail should be managed in a standardized way, such as the doctor's advice execution process, doctor's advice execution process and handover process, patient notification process after arrears, patient rescue process, and critically ill patient care process.

7. Implement the basic nursing quality management system of the nurse in charge: the nurse in charge is mainly the nursing team leader, and her duty is to check and assess the completion of the basic nursing work of other nurses in this shift on the basis of completing this specific work. The head nurse implements the daily responsibility system, and requires the nurse in charge to report the completion of basic nursing to the head nurse voluntarily before work every day: 1) What work has the nurse in charge instructed, and 2) What inspections have been made on the basic nursing work? 3) Is there any communication with the nurse himself in the place that is not in place? Every week, the nurse in charge should summarize the basic nursing care for one week, put forward the existing problems, analyze the reasons and propose solutions. At the end of each month, the performance workload coefficient and post coefficient of the nurse in charge will be improved.

8. Establish a self-inspection table for the completion of nurses' shift responsibilities: list the responsibilities and workload that need to be completed in each shift into a table according to the procedure, so that nurses can check the completion of their shift responsibilities according to the table.

Second, the daily work implementation plan:

(1) Basic nursing and critically ill patient care: From the morning care, continue to strengthen the implementation of morning care by nurses, improve the procedures of morning care, and change the morning care to simply complete the replacement and arrangement of patients' bed units. In the morning care, the responsible nurse starts from greeting patients, helping patients who can't take care of themselves to get up, gargle and excrete, and then assisting patients to eat; In addition to closely observing the patient's condition and carrying out basic nursing such as correct medication, oral care, pressure sore care and airway according to the doctor's advice, the responsible nurses in each group assist the patients who can't take care of themselves with perineal care, hot water soaking their feet and scrubbing their backs every afternoon from 2: 30 to 3: 00. Critically ill patients are centrally managed by senior nurses, making nursing plans, and implementing various nursing and treatment strictly according to the plan. Check the critically ill patients in shifts, and check the implementation of various treatments and nursing. The nurses who take over only listen to the nurse's narration, but do not check the results of the implementation of various treatments and nursing, so as to ensure the implementation of the nursing plan for critically ill patients, recover smoothly and improve the nursing quality of critically ill patients.

(2) Admission guidance and health education:

1, give detailed admission guidance to patients and their families. Nurses should take the initiative to introduce themselves when explaining, first explain the responsibilities and obligations of nurses to patients, and then explain hospitalization rules and regulations and matters needing attention to patients. Nurses should use civilized language and use respectful names for patients.

2. Compile the pharmacological effects, adverse reactions and precautions of various commonly used drugs into a book, organize nurses to learn, make nurses familiar with the pharmacological effects and precautions of drugs, form the habit of nurses reading instructions frequently, and explain the precautions in drug use to patients according to the instructions.

3. Ask the nurse in charge to explain the types and precautions of various drugs used to the patients in the time periods of 10am- 10:30am and 3: 00pm-3: 30pm, and explain to the patients every treatment, nursing and examination item and precautions that the patients need to carry out on the same day and the next day, so that the patients can fully understand their own treatment, nursing and examination items.

4, the head nurse insisted on daily communication with all patients, understand the patients' mastery of their own treatment and medication, timely supplement the problems missed by nurses, and improve patient satisfaction.

(3) Quality control

1, the head nurse should check the night shift work at least 2-3 times a week, especially the nurses with weak sense of responsibility, strengthen dynamic monitoring and recording, strengthen education and communication with them, and focus on improving the shortcomings and bad work habits of these nurses.

2. The head nurse regularly issues satisfaction questionnaires every week, checks the satisfaction of night shift work, asks patients about night shift nurses, and explains to patients that they should not have any ideological concerns, so that patients can truly reflect the work of night shift nurses, which has played a very good supervisory role.

3, set up a night shift nursing team leader, the team leader is responsible for the quality control of night shift nursing, check the work completion of each group of nurses, check the nursing situation of critically ill patients for two hours at night, and supervise the service attitude of night shift nurses. The night shift leader will record the night inspection in the quality inspection record book, and at the morning meeting *, which will be linked to the monthly assessment and performance pay of nurses after being implemented by the head nurse.

4, the head nurse's daily quality control focus

1) Go to work at 7: 30 every morning, and patrol the ward again to check the completion of night shift work, check whether all kinds of pipes of patients are in place, and understand the situation of patients at night.

2) During the morning meeting, it is necessary to coordinate and guide the work priorities and critical patients of the day, and ask the nurses about their professional knowledge, the nurses' mastery of the patients' condition, and the nurses' mastery of the emergency treatment of critical patients.

3) bedside *, check the night shift nurse to the bedside nurse to explain the patient's condition, the day's inspection and test results, understand the nurse's grasp of the patient's six senses, and check the patient's various pipes, skin, deep vein and deep vein length in detail. Check the patient's vital signs, blood sugar, drainage volume and urine volume.

4) Check the configuration of nutrition bags and the use of insulin in the ward.

5) Check whether the first-aid drugs and instruments are working normally, and whether the drugs are filled and effective.

6) Cooperate with clinical classes to handle doctor's orders and check the implementation of doctor's orders.

7) Visit the ward again in the morning 10 to check the implementation of patients' various treatments, check the morning care and the cleanliness of the bed unit, understand the admission guidance of newly admitted patients, check the hygiene situation of the ward and the psychological state of patients, understand the patients' mastery of activities and health guidance after operation, and understand the use of ECG monitors and micropumps.

8) Check the drug management in the treatment room.

9) At 2:30 p.m., shift with the bedside of the clinical class to understand the patient's condition, treatment and various pipelines.

10) Check the first three pages of medical records according to the doctor's advice.

1 1) Conduct operation guidance training and assessment for ward nurses within two years, and check the treatment implementation and nursing of surgical patients and critically ill patients.

13) and the night shift nurse handed over to the bedside, handed over the patient's condition, the examination and test results of the day in detail at the bedside, asked the responsible nurse about the mastery of the patient's six senses, and inspected the patient's various pipes, skin, deep veins and deep vein lengths in detail. Check the patient's vital signs, blood sugar, drainage volume and urine volume.

(4) Specimen collection, inspection and examination: explain in detail the appointment process of patient examination items. Every time the patient is examined, the responsible nurse submits the doctor's advice in time. When dealing with the doctor's advice, it is necessary to strictly check whether there is a checklist. If there is no checklist, urge the doctor to write it in time, and then give it to the patient, and explain the inspection precautions to the patient in detail. If it is an emergency examination, you must contact China Shipping in time; If it is a flat diagnosis, you should patiently explain to your family members and patients and wait for the central transportation to pick up the patients. Don't let patients go to the examination department for examination without permission. However, if the patient needs surgery the next day, the nurse should remind the doctor to open an emergency examination and contact the center for transshipment in time to avoid affecting the patient's surgery. For blood samples, the nurse should strictly check the doctor's advice, check the name at the bedside in time when drawing blood, and check whether the patient is a matched blood sample before each blood draw. It is not allowed to draw blood samples from two people at the same time to avoid mistakes. The prepared blood sample should be notified to the doctor in time and sent to the blood transfusion department by the doctor. Other blood and body fluid samples must be taken and collected before collection and registration.

(5) Management of drugs and articles in the treatment room: During the shift change and night shift every day, all kinds of articles, drugs and highly toxic drugs should be handed over strictly, and the records should be clear, and they should not be altered, and the quantity should be consistent. The counter where toxic drugs are used should be locked, and the doctor's advice and prescription should be obtained, and the drugs should be collected from the pharmacy in time *; Drugs and liquids should be clearly marked within the validity period, and there are no drugs and liquids that are deteriorated, discolored and moldy; The medicine cabinet shall be cleaned once a day, and the medicines shall be classified and placed neatly, without empty boxes, bottles and sundries, and the medicines shall not be mixed; Get the patient's medicine from the pharmacy in time. Those who lack medicine or owe money should inform both doctors and patients in time, and return the patient's medicine in time. During the shift change, the atomizing inhaler, humidifying bottle, micro-injection pump and monitor shall be counted daily and maintained once a week, and any faults shall be guaranteed in time.

(6) Disinfection and isolation: The responsible nurse cleans the surfaces and cuffs of the stopped instruments with alcohol, and then submits them to the treatment class for supervision and inspection. If the treatment class is not checked, the treatment class will be responsible for disinfection and classification. After each use of the aerosol inhaler, empty the water in the sink, dry it and keep it dry. After changing the humidification bottle every day, tear off the adhesive tape before soaking and disinfection, rinse it with clear water after shift change, and dry it before going to work every day. All kinds of aseptic items in the locker room are inspected daily, put in order of validity, and used in order when using. Iodophor disinfectant and dry tweezers jar must have an opening date; During the shift change, the countertops and floors of the treatment car, treatment room and dressing room should be kept clean every day, medical wastes should be placed in different categories, trash cans should be kept clean, and needles should be put in boxes.

(7) First-aid articles and medicines: Pro A3 is responsible for checking first-aid articles, instruments and medicines, checking and supplementing them in time every day to ensure the normal operation of medicines, articles and instruments, and making clear records during the shift change. First-aid instruments, articles and medicines should be checked during night shift. The head nurse should check the situation of first-aid drugs, articles and equipment every day.

In 20XX years, under the leadership, help and guidance of hospital leaders, nursing directors and head nurses, we mainly did the following work. A, ward nursing management

Come to work in general surgery for one year, study professional knowledge hard and overcome the shortcomings in business. When the rescue and ward staff are nervous (such as holidays), they can take the lead and directly participate in patient care.

According to nursing quality standards, establish various work routines. Monitor and record all kinds of quality indicators, and improve them in time if any deficiencies are found. Using pdca quality improvement method to implement cqi project at the grass-roots level. In the implementation, the enthusiasm of nurses was fully exerted, the management of deep vein was improved, the standardized evaluation of patients was promoted, the health education of patients was improved, and the standardized implementation of the handover system was improved.

Promote standardized records of medical records, check them regularly, and feed back the results to relevant nurses in time to help nurses improve the standards of incident handling, reporting and discussion.

Second, personnel management.

In 20XX, this floor accepted * new transferred comrades and * * new working comrades, and all of them were able to arrange departments for standardized pre-job training and give serious teaching and guidance, so that new nurses could adapt to their work as soon as possible.

13 years, according to the requirements of the Ministry of Nursing Education, on the basis of collecting the education needs of nurses in departments, * * * arranged nursing rounds * * * times and arranged business study hours * * *.

In the aspect of employee motivation, through the combination of continuous nurses' timely evaluation feedback and quarterly evaluation, nurses can be helped to continuously improve their work, praise good behaviors in time and promote a good working atmosphere.

By means of authorization, nurses are encouraged to participate in department management, and almost every nurse is directly responsible for a new department management content to stimulate nurses' work enthusiasm.

Support and encourage nurses to continue their studies. There are nurses who carry out continuing education with academic qualifications. As head nurses, they try to make the work arrangement convenient. At the same time, nurses are encouraged to learn English, and the department organizes Professor Qi to give lectures to help nurses improve their English.

In the absence of teaching, we can give full play to the enthusiasm of department nurses and undertake the teaching work of students together. Various small lectures have won the praise of students and improved the teaching ability of nurses in the department.

Arrange nurses to go out to class.

Third, the work management

Carry out floor cost accounting management according to hospital requirements. Fixed the number of weekly deliveries in the supply room. According to the requirements of the hospital, standardized management of fees. Standardize the finance and goods of the management department and check them regularly.

Adjust the position of items on the floor to make the floor environment cleaner.

Reaffirm the system of departmental shift arrangement and shift change, and promote nurses to shift change according to the standard. According to the patient's situation, provide appropriate nursing manpower, ensure nursing effect and arrange manpower reasonably.

Actively participate in the meetings held by the hospital and nursing department, hold a nurse meeting once a month, and convey the working ideas and work arrangements of the hospital and nursing department to clinical nurses in time. According to the purpose and goal of the hospital, guide nurses to follow.

Actively promote the cooperation between nursing department and other departments, help the director of general surgery to undertake part of the management work, and promote the cooperation between doctors and nurses.

As a major member of the Communication Committee, actively participate in the activities of the Committee and promote its development.

Fourth, their own career development.

Under the condition of effectively completing the task of ward nursing management, we should learn all kinds of professional knowledge and improve our ability in all aspects.

/kloc-in 0/3 years, he obtained the bachelor's degree certificate of nursing night university and the Chinese undergraduate diploma. Continue to study medical English.

Completed the training of picc puncture in hospital.

Learn to use computers to improve work efficiency.

Under the arrangement of the leadership of the nursing department, I attended classes * * times, went out to attend academic conferences * * times, and was invited to give lectures * * times.

Write a thesis and pass the preliminary examination of practical nursing. Complete the continuing education credits stipulated by the hospital, especially actively participate in various management courses.

A new year, a new beginning, work harder and study harder in the coming year, and do not undertake the training of hospitals. The goals for next year are:

1. Continue to learn English, and strive for a great improvement in use and spoken English next year, so as to communicate with foreign experts more fluently. Take CET-6 or CET-4.

2. More progress has been made in management knowledge and skills. The ways to improve are: reading management books, communicating with other head nurses and attending management courses.

3. Actively participate in scientific research group activities and publish 1-2 papers.

Based on the "quality nursing service" activity in 20XX, in order to further deepen the connotation of "quality nursing service" and take "improving professional quality and optimizing nursing service" as the theme, the service level is continuously improved, and the whole process quality management of all nursing work is carried out with a rigorous attitude. On the basis of summarizing the experience of "quality nursing service" in the previous year, the "quality nursing service" for 20XX years was formulated.

Overall guiding ideology

Follow the working policy of "focusing on nursing service and developing characteristic specialties", take strengthening the quality construction of nurses as the core, pay attention to specialties and training, provide patients with safe, professional and full-course quality nursing services, and enhance patients' satisfaction with nursing services.

First, strictly implement the overall nursing responsibility system.

(1) Wards are arranged flexibly, such as night shift, middle shift and holidays. Reduce shift frequency, reduce work loopholes, reasonably match young nurses and old nurses on duty, and pay attention to cultivate the spirit of caution and independence when nurses are on duty independently.

(2) According to the concept of high-quality nursing service, there are 2 responsible group leaders and 2-3 bed nurses in the ward, and each nurse cares for 10 patients. The responsible nurse provides patients with continuous and complete work from admission to discharge, including various treatments, medication, observation of illness, basic nursing and health education, so as to effectively provide high-quality nursing services. Critical patients, high-risk patients after major surgery and complications are implemented by senior responsible nurses.

(3) fully perform the duties of nurses. It integrates basic nursing, disease observation, treatment, communication and health guidance to provide patients with comprehensive, whole-course and continuous nursing services. Close observation of patients' condition, timely communication with doctors, communication with patients, health education and rehabilitation guidance for patients, and psychological care.

(4) Clinical nursing service fully embodies the characteristics of specialties, enriches the service connotation according to the characteristics of departments, provides humanized nursing service for patients, ensures the safety of patients and promotes their rehabilitation.

Second, strengthen nursing safety management and improve nursing risk prevention measures.

(1) Strengthen the care of key patients: for example, surgical patients, critically ill patients and elderly patients, take these patients as the focus of discussion at the early meeting or shift change, evaluate the existing and potential risks of patients, reach a * * * understanding, and attract the attention of each class. Do a good job in the handover of critically ill patients, pressure ulcer prevention, blood transfusion, special medication, patient pipeline management and patient existing and potential risk assessment.

(2) further standardize the writing of nursing documents, reduce potential safety hazards, pay attention to the problems existing in nursing documents at this stage, and make the records "objective, true, accurate, timely and complete" to avoid irregular writing, such as typos, unclear alterations, inconsistencies with doctors' records, etc., so as to standardize and standardize nursing documents.

(3) Improve the emergency risk plan of nursing, pay attention to cultivating nurses' emergency ability at ordinary times, and make a retrospective evaluation of various emergency work, such as blood transfusion, transfusion reaction, special liquid, drug leakage, sudden power failure, etc. So as to learn from it and improve the ability of nurses to deal with emergencies.

(4) Strengthen the monitoring and management of nursing safety, organize the departments to investigate the hidden dangers of nursing safety and analyze and discuss the causes of nursing errors and nursing input every month, analyze the reasons and lessons to be learned, and put forward preventive measures and improvement measures.

(5) Strengthen departmental management. Conduct irregular spot checks on ward management, basic nursing, nursing safety, medical record writing, nurse equipment, disinfection and isolation every week, immediately point out the existing problems and give feedback within a time limit, and summarize them at the monthly nurse work meeting; Quality control of high quality nursing wards. Third, comprehensively improve professional quality and optimize nursing service.

(1) Strengthen the "three basics" training plan to improve the comprehensive quality and professional ability of nursing staff.

(2) To learn basic nursing service items, basic nursing service standards and common clinical nursing technical service standards for inpatients.

(3) Organize all nurses to conduct business study, nursing discussion of critically ill patients, case rounds, education rounds and other forms of learning and training every month, so as to improve the professional quality of nursing staff in the hospital and their ability to observe the illness, implement nursing measures and record nursing documents.

(4) Improve the practical working ability of clinical nurses and cultivate the backbone of specialized nursing.

(5) simplify the morning collective * strengthen the bedside * content. Using the time of bedside shift change, head nurses and senior nurses explain the theoretical knowledge of bedside specialty and take effective intervention measures on the first-class nursing and nursing problems of critically ill patients.

(6) Supervise the nursing staff to seriously implement the nursing routine, nursing system, nursing operation rules and condition observation, and conduct regular first-aid technical drills, so that every nurse can master the use of first-aid drugs and instruments. Fourth, deepen the quality of nursing service with the overall goal of patient satisfaction.

Take patients as the center, advocate humanized service, strengthen nurse-patient communication, improve patient satisfaction and avoid nursing disputes.

(1) The nurse in charge sincerely received the patients, sent them to the bedside, and actively provided health education for the discharged patients.

(2) Strengthen service awareness education, improve the concept of humanized active service, increase health education days on basic nursing days every Wednesday and Sunday, and make education guidance and safety precautions at any time in each class.

(3) hold a symposium every month to solicit opinions from patients and their families, and praise, criticize and educate nurses with good or bad service quality.

Five, strengthen the training of hospital infection knowledge, prevent and control the occurrence of hospital infection.

1, learn the knowledge of hospital sense once a month.

2. Sterile articles should be placed separately from non-sterile articles, and the used sterile articles should be marked with the opening time in time and disinfected regularly; Every day, the nurse in charge of the treatment class will check and disinfect the items.

3, the medical waste placed separately, every day before coming off work by the nurse on duty to check, and urge the nursing staff to do a good job of garbage Nissan Nissin; Nurses with disinfection monitoring regularly carry out publicity and education work in the department.

4, disinfectant concentration monitoring, air culture, surface culture, etc. , by the disinfection monitoring nurse is responsible for, and timely record. The head nurse will monitor the examination results from time to time, and formulate relevant nursing measures in time to ensure the safety of nursing.