NursingwardroundinEnglish

September2012

Theconditionofthis

Patient

(wunanzhen)ThePatient,male,76yearsold,15daysagoafterthecoldhehadcough,sputum,sputumwithblood,Accompaniedbyshortnessofbreath,Shortnessofbreathafteractivityincreasedslightly,Withoutchills,fever,chestpain.病例概述

患者，男性，78歲，老年性肺炎患者訴15天前因受涼后出現(xiàn)咳嗽、咳痰，痰中帶血絲，伴氣促，稍活動后氣促即加重，無畏寒、發(fā)熱，無胸痛。Atthelocalhospitalfortreatmentwithantibiotics,specificagentsisunknown,TheSymptomsarenotcontrolled,andgraduallyincreased.在當?shù)蒯t(yī)院予以抗感染治療，具體藥物不詳，癥狀未予控制，并逐漸加重。Withnocturnalparoxysmaldyspnea,butwithoutchestpain,Forfurthertreatment,andthentoourhospital.有夜間陣發(fā)性呼吸困難，無胸痛，為求進一步診治，遂入我院就診。InSeptember4,201215:30,thispatientontheflatcaradmittedtoemergencyform,Inourdepartment,Diagnosisof“TheSenilepneumonia”.于2012年9月4日15：30急診平車入院，以“老年性肺炎收住我科。Inthistimewiththepatientsick,hisspiritandappetitearenormal,fecesandurinearenormal,poorsleep,weightdoesnothaveapparentchange.患者自起病以來，精神食欲可，大小便正常，睡眠欠佳，體重無明顯改變。

Theadmissionexamination:temperature:37.2degreescentigrade,pulse:100timesperminute,breathing:20timesperminuteBp:160/90mmHg.Sane,lipsnocyanosis.Lungauscultation:breathingsoundrough,twolungmayhearandlittlemoistrales.thelegsnoedema.入院查體：T：37.2℃，P:100次/分，R:20次/分，Bp:160/90mmHg。神清，口唇無發(fā)紺。肺部聽診：雙肺呼吸音粗，兩肺可聞及少量濕性啰音。雙下肢無浮腫。Pasthistory

Thispatienthad"hypertension,cerebralarteriosclerosis,coronaryheartdisease,chronicobstructivepulmonarydisease"formorethan10years,Hasalonghistoryofuseofantihypertensivedrugs.既往史既往有“高血壓病3級極高危組、冠心病、腦動脈硬化、慢性阻塞性肺氣腫疾病”10余年病史，有降壓藥長期服藥史。

In52yearsago,hehavethetraumaoperationhistory,andmanyplaceofthewholebodyisthebombfragmentinjury.ThePatientwithasmokinghabit,smoking23years,daily60branch.Havingquitsmoking.Quitsmokingfor21years.52年前因外傷手術(shù)史，有52年前全身多處被炸彈碎片擊傷外傷史，患者有吸煙嗜好，吸煙23年，每日60支。有戒煙。戒煙21年。Auxiliaryexamination

Routinebloodtestresults:anormalleukocytecount,neutrophilslightlyhigher.ChestX–rayshowed:twolungpatchyinfiltrationofshadow,andaccompaniedbypleuraleffusion.

輔助檢查血常規(guī)結(jié)果示：白細胞計數(shù)正常，中性粒細胞稍增高。胸部X片結(jié)果示：兩肺斑片狀浸潤性隱影，并伴有胸腔積液。LungComputerizedTomography(CT)indicated:pulmonaryinfection.Arterialbloodgasresultsshow:Partialpressureofoxygenis80mmHg,Partialpressureofcarbondioxideis40mmHg,Bloodoxygensaturationis90%.Electrocardiographicfindingsshow:atrialfibrillation,multipleventricularpremature.肺部CT示：肺部感染。ABG結(jié)果示：PO280mmHg,pco240mmHg,SaO2:90%。心電圖結(jié)果示：房顫、多發(fā)室早。admittingdiagnosis：

(sumin)Pneumonia.Chronicobstructivepulmonarydisease.Coronaryheartdisease,HeartfunctionclassⅢ,Arrhythmia,Multipleroomsexprematurebeat,Rapidatriafibrillation.Hypertension,gradeⅢ,extremelyhighriskgroup.入院診斷1、肺炎；2、慢性阻塞性肺氣腫；3、冠心病心功能3級心律失常多發(fā)室早快速房顫；4、高血壓病3級極高危組。therapeuticprocess:

Afteradmission，withCefodizimefightinginfection、ambroxolresolvingthephlegmaerosolinhalation、vibrationsputumdiscarding.治療經(jīng)過患者入院后，醫(yī)囑予頭孢地嗪抗感染治療，予氨溴索祛痰治療，同時輔助予霧化吸入及振動排痰。MeglumineadenosinecyclophosphateImprovingcardiacfunction、digoxinstrengtheningtheheart、mexiletinecontrolingarrhythmia,theeffectofallthesetreatingsarenotbeautifulaweeklater.予環(huán)磷腺苷葡胺改善心功能，地高辛強心，美西律控制心律失常?；颊呷朐嚎垢腥局委熞恢芎笮Ч患选hepatientisstillbeingcough、sputumandshortnessofbreath,aftercheckingbloodpicturehigh,wechangecefodizimetomeropenemfightinginfection.患者仍有咳嗽咳痰氣促，復查血常規(guī)血象升高，醫(yī)囑予停用頭孢地嗪，現(xiàn)改用美羅培南抗感染治療。presentconditions

Atpresent，thepatientisconsciousandfeelfit.thetemperatureandthebloodpressurearenormal,butafterexerciseitwillcausesymptomssuchaspalpitationand

shortnessofbreaththesymptomshaveimproved.thereisnobloodinsputum.theneckveinisenlarged，Doublelungbreathsoundscoarse.目前情況

患者目前神清，精神可。體溫、血壓正常，訴活動后心悸氣促癥狀略有減輕，痰中無血，頸靜脈充盈，口唇無發(fā)紺，雙肺呼吸音粗。Afewmoistandrhonchiraleshavebeenaudibleoverbothlung.heart

rateisninetypermin.thepulserateisuntidy.Pulsedeficit.Pulmonaryinfectionispoorlycontrolled.Thepatientstillhascoughandshortnessofbreath.雙肺可聞及干濕性啰音，心率90次\分，律不齊，第一心音強弱不等，肺部感染仍控制不佳，仍有咳嗽氣促。

Nursingdiagnosisandnursingmeasures

（suli)1、IneffectiveAirwayClearance:

Lunginfection,trachealandbronchialsecretionsincrease,stickyandfatigue

are

related①Observation

:

Closelyobservecough

and

coughphlegmsituation,

Includingsputumcolor,quantityandcharacter,

And

whether

expectorationissmooth

ornot.主要護理診斷及護理措施

1、清理呼吸道無效：與肺部感染，氣管、支氣管分泌物增多、黏稠及疲勞有關①病情觀察：密切觀察咳嗽咳痰的情況，包括痰液的顏色、量及性狀，以及咳痰是否順暢。②Medicationnursing:

Followthedoctor'sadvicetoanti-inflammatory,cough,expectorant,Noticethedrugcurativeeffectandadversereaction.③Tokeeprespiratorytractunobstructed:

Instruct

the

patient

to

have

morewater,inordertoachieveawetprocessairway

and

dilution

sputum

.②用藥護理：遵醫(yī)囑予以抗炎，止咳，祛痰藥，注意觀察藥物療效和不良反應。③保持呼吸道通暢：指導病人多飲水，以達到濕化氣道，稀釋痰液的目的。2、Gas

exchangedamaged:

airwayobstruction,lackofventilationandrespiratorymusclefatigue,secretiontoomuchandalveolarbreathingareareduce

are

relevant(1)Restandactivity:

Thepatienttotakeacomfortableposition,dependingontheconditiontoarrangetheproperactivity,theactivitytonotfeelingfatigue,don'taggravatesymptomsadvisable.2、氣體交換受損：與氣道阻塞、通氣不足、呼吸肌疲勞、分泌物過多和肺泡呼吸面積減少有關①休息與活動：病人采取舒適的體位，視病情安排適當?shù)幕顒恿?，活動以不感疲勞、不加重癥狀為宜。

4、Havethe

dangerofbeinginjuried:relatedwithdizziness,faintcausedbyarrhythmia.（1）Assess

riskfactors:askthepatientwhetherhavesomeincentivefactorsandaurasymptomsbeforesyncopeandunderstandtheposition,durationandaccompanyingsymptomsetc.ifnecessary,usingECGmonitoringtoobservethetypeofarrhythmia.4、有受傷的危險：與心律失常引起的頭暈、昏厥有關（1）評估危險因素：向病人及知情者詢問病人暈厥發(fā)作前有無誘因及先兆癥狀，了解暈厥發(fā)作時的體位、暈厥持續(xù)時間、伴隨癥狀等。必要時心電監(jiān)護，動態(tài)觀察心率失常的類型。（2）Stayinbedandstrengthenthecaretothelife，ifthepatienthavedizziness

,attackedbysyncopeorthehistoryoffallandinstructclienttoavoidgoingoutalonetopreventfromaccident.（2）有頭暈、暈厥發(fā)作或曾有跌倒史者應臥床休息，加強生活護理。囑病人避免單獨外出、防止意外。（3）

avoidincentive:toldclienttoavoidstrenuousactivity,moodexcitedornervous,changeofpositionrapidandsoon.Inordertoavoidinjuries,oncethepatienthavetheauraofdizzinessamaurosiskeeprecumbent

immediatelly.（3）避免誘因：囑病人避免劇烈活動、情緒激動或緊張、快速改變體位等，一旦有頭暈、黑蒙等先兆時立即平臥，以免跌傷。（4）Givetreatmentfollowthedoctor'sadvice:givedigoxin,mexiletinetothepatientswhohaveatrialfibrillationandstartearlyofthemulti-pleventricular

tocontrolarrhythmiafollowthedoctor'sadvice,andlookatthereaction.(4)遵醫(yī)囑給予治療：該病人有房顫和多發(fā)室早，應遵醫(yī)囑給予地高辛、美西律控制心律失常，并注意觀察用藥后反應。

(longlijuan)5、Potentialcomplications:infectiousshock,highbloodpressureemergency,respiratoryfailure,heartfailure,stroke5、潛在并發(fā)癥：感染性休克、高血壓急癥、呼吸衰竭、心力衰竭、猝死

（1）Avoidincentive:toclarifythepatientundesirablemoodmayinducevariouscomplications,shouldavoidmoodexcited,keepmoodcalm,relaxed,stability.Accordingtothedoctor'sadvicetotaketheguidanceofanti-hypertensivedrugs,asfaraspossibleavoidoverfatigueandcoldstimulation.（1)避免誘因：向病人闡明不良情緒可誘發(fā)各種并發(fā)癥的發(fā)生，應避免情緒激動，保持心緒平和、輕松、穩(wěn)定。指導其按醫(yī)囑服用降壓藥物，盡量避免過勞和寒冷刺激。(2）Conditionmonitoring:monitoringpatient'slifesignsandsymptoms,oncefoundasharpraiseorlowerofthebloodpressure,heartrateincreasingfast,difficultybreathing,bodytemperaturedoesnotriseorhighfever,severeheadache,vomiting,bigsweat,blurringofvision,complexionandmindchange,bodymovementdisorders,andsoon,immediatelynotifythedoctor,andreadyforitems,andactivelycooperatewiththerescue.(2)病情監(jiān)測：監(jiān)測患者的生命體征，一旦發(fā)現(xiàn)血壓急劇升高或降低、心率增快、呼吸困難、體溫不升或高熱、劇烈頭痛、嘔吐、大汗、視物模糊、面色及神志改變、肢體運動障礙等癥狀，立即通知醫(yī)生，并備好物品，積極配合搶救。(3）therescueofSepticshock:1）Position:thepatienttakeonyourbackinthenotches,raisecephalothorax20degrees,driveuplowerlimbabout30degrees.Itwillbehelpfulforbreathingandvenousreturn.

(3)感染性休克搶救配合：1)體位：病人取仰臥中凹位，抬高頭胸部20度、抬高下肢約30度，有利于呼吸和靜脈血回流。2）Oxygen:givehighflowoxygen,maintainoxygenpartialpressure>60mmHg,improvetheanaerobiccondition.3）Addedbloodvolume:fastestablishtwovenouspath,followthedoctor'sadvicetogivedextranorbalancefluidtomaintaineffectivebloodvolume,reducebloodviscosity,preventdiffuseintravascularcoagulation;Haveobviousacidosiscanbeused5%NaHCO3staticdrop.2)吸氧：給予高流量吸氧，維持氧分壓＞60mmHg，改善缺氧狀況。3)補充血容量：快速建立兩條靜脈通路，遵醫(yī)囑給予右旋糖酐或平衡液以維持有效血容量，降低血液粘滯度，防止彌散性血管內(nèi)凝血；有明顯酸中毒可應用5%NaHCO3靜滴。4）Medicationnursing:Followthedoctor'sadviceinputdopamine,betweenthehydroxylamine(alamine)andvasoactivedrugs.Combineduseofbroad-spectrumantibacterialdrugcontrolinfection,shouldpayattentiontodrugcurativeeffectandadversereaction.4)用藥護理：遵醫(yī)囑輸入多巴胺、間羥胺（阿拉明）等血管活性藥物。聯(lián)合使用廣譜抗菌藥物控制感染時，應注意藥物療效和不良反應。（4）Highbloodpressureemergencycare:Thepatientabsolutebedrest,raisetheheadofabed,avoidanybadstimulationandunnecessaryactivities,assistlifecare.Tokeeprespiratorytractunobstructed,oxygen.

(4)高血壓急癥的護理：病人絕對臥床休息，抬高床頭，避免一切不良刺激和不必要的活動，協(xié)助生活護理。保持呼吸道通暢，吸氧。

Emotionalstabilityandpatient,whennecessary,usedepressant.Connectionkindelectric,bloodpressure,breathingguardianship.Quicklyestablishingvenouspath,followthedoctor'sadviceasearlyaspossibleapplicationofanti-hypertensivedrugs,drugprocessnotemonitoringbloodpressurechange,avoidbloodpressuredip.安定病人情緒，必要時使用鎮(zhèn)靜劑。連接好心電、血壓、呼吸監(jiān)護。迅速建立靜脈通路，遵醫(yī)囑盡早應用降壓藥物，用藥過程注意監(jiān)測血壓變化，避免出現(xiàn)血壓驟降。（5）Thenursingofrespiratoryfailure:1)Tokeeprespiratorytractunobstructed:a:removalofsecretionofrespiratorytractandforeignbodyb:alleviatebronchospasmc:establishingartificialairway(5)呼吸衰竭的護理：1)保持呼吸道通暢：a、清除呼吸道分泌物及異物，b、緩解支氣管痙攣，c、建立人工氣道2)Oxygentherapy3)Increasingventilation,reduceCO2retention:a:breathingstimulantb:mechanicalventilation4)Fightinfection5)Correctacid-basebalance2)氧療3)增加通氣量、減少CO2潴留：a、呼吸興奮劑，b、機械通氣4)抗感染5)糾正酸堿平衡(6)Heartfailurecare:Assistclienttoimmediatelytakeseat,doublelegprolapse,give6~8l/minhighflowoxygeninhalation.(6)心力衰竭的護理：立即協(xié)助病人取坐位，雙腿下垂，給予6~8L/min的高流量氧氣吸入。Quicklyestablishingtwovenouschannel,morphinecalmandfurosemidediuresis,sodiumnitroprusside,nitroglycerinorphentolamineexpandbloodvessel,digitalispreparationprotectingheartandaminophyllineremovebronchospasm.Rigorousmonitoringconditionchanges.迅速建立兩條靜脈通道，嗎啡鎮(zhèn)靜，呋塞米利尿，硝普鈉、硝酸甘油或酚妥拉明擴張血管，洋地黃制劑護心，氨茶堿解除支氣管痙攣。嚴密監(jiān)測病情變化。(7)suddendeathnursing:establishingvenouspath,readyforanti-arrhythmicdrugsandotherrescuedrugs,defibrillator,temporarypacemaker,etc.（7）猝死的護理：建立靜脈通路，備好抗心律失常藥物及其他搶救藥品、除顫儀、臨時起搏器等。Timelyfollowthedoctor'sadvicetogivedrugtherapy,whennecessary,cooperatewithtemporarycardiacpacemakerorcardioerter.Onceproducesuddendeathperformancesuchasconsciousnesssuddenlyloses,convulsions,aortabeatingdisappear,respiratoryarrest,immediatelytorescue.及時遵醫(yī)囑給予藥物治療，必要時配合臨時心臟起搏或電復律。一旦發(fā)生猝死的表現(xiàn)如意識突然喪失、抽搐、大動脈搏動消失、呼吸停止，立即進行搶救。6、AnxietyworriedaboutthediseaseprognosisNursingstaffshouldbedetailedunderstandingofpatientsandtheirfamiliestodiseaseattitude,caringpatients,understandthepatientpsychologyandpersonality,lifestyle,etcforsickandchange,andpatientsandtheirrelativesonacommonformulationandimplementationrehabilitationplan.6、焦慮與擔心疾病預后有關護理人員應詳細了解病人及其家庭對疾病的態(tài)度，關心體貼病人，了解病人心理、性格、生活方式等方面因患病而發(fā)生的變化，與病人和家屬共同制定和實施康復計劃。Eliminateincentive,regularbreathingmachinefunctionexercise,reasonableuseofantibiotics,relievesymptoms,enhancetheconfidenceofconquerdisease.消除誘因、定期進行呼吸機功能鍛煉、合理用藥等，減輕癥狀，增強戰(zhàn)勝疾病的信心。Totheperformanceanxietyofpatients,thechurchpatientsrelieveanxietymethods,suchaslisteningtolightmusic,playchess,suchasgameforrecreationalactivities,inordertodivertattentionfrom,reduceanxiety.對表現(xiàn)焦慮的病人，教會病人緩解焦慮的方法，如聽輕音樂、下棋、作游戲等娛樂活動，以分散注意力，減輕焦慮。Healtheducation

(heshu)1、maintainthegoodlifehabit,payattentiontoadullboy,sufficientrest.2、inordinarylife,COPDpatientsshouldexercisebasedontheirownphysicalconditionsuchasimprovetheresistanceandlungfunction,etc.3、avoidcontactoreliminateinducedfactors,suchasdust,dietandhealth.respiratoryinfections,germs,etc.

健康教育1、保持良好的生活習慣，注意勞逸結(jié)合,充足休息。

2、在平時生活中,慢阻肺患者應根據(jù)自身的體質(zhì)及病情選擇合適的項目進行鍛煉，提高抵抗力及改善肺功能等。

3、盡量避免接觸或消除誘發(fā)因素，如粉塵、飲食衛(wèi)生、呼吸道感染、病菌等。

4、SmokingisthemaincauseofCOPD,sogiveupsmokingassoonaspossibleisthekeyofpreventionCOPDdisease.5、Keepgooddietarycollocationinlifeisnecessary,ofseasonablecompensatorybodyneedednutrientsandenergy,trytoavoideatingcrude,coldandasweet,spicy.6、Staycalmandavoidemotionalandexcessivetension,anxiety,whenanythingcropsuptocalm.4、吸煙是造成及促發(fā)慢阻肺疾病的主要原因，所以及早戒煙也是預防慢阻肺疾病的關鍵。

5、在生活中還應保持良好的膳食搭配，及時補充身體所需的營養(yǎng)及能量，盡量避免食用生冷、過甜、過辣等的刺激性食物。

6、保持平靜的心境，避免情緒激動及過度緊張、焦慮，遇事要沉著冷靜。7、Mustadheretothelong-termuseofantihypertensivedrugs,andunderstandtheeffectandsideeffectsofmedicines,monitoringthebloodpressureregularly.8、Applicationantihypertensiveprocess,actionshouldtrytoslowiy,especiallythenightupurinatemoreattentionshouldbepaidto,inordertoavoidbloodpressuredropssuddenlycausesyncope.7、必須堅持長期服用降壓藥，并了解藥物的作用和副作用，定期監(jiān)測血壓。

8、應用降壓藥過程中，從坐位起立或從平臥位起立時，動作應盡量緩慢，特別是夜間起床小便時更要注意，以免血壓突然降低引起暈厥而發(fā)生意外。9、Completesthecoronaryheartdisease“secondaryprevention”:primarypreventionisfocusedonbloodlipid,bloodglucose,bloodpressure;Secondarypreventionarticle5lines:A:takingaspirinandangiotensinconvertingenzymeinhibitor9、做好冠心病的二級預防：一級預防重點是干預血脂、干預血糖、干預血壓；二級預防的5條防線是：A、服用阿司匹林及血管緊張素轉(zhuǎn)換酶抑制劑。B:takingβ-receptorblockersandcontrolofbloodpressureC:lowercholesterolandquitsmokingD:controllingdiabetesandreasonabledietE:movementandhealtheducation

B、服用β受體阻滯劑和控制血壓

C、降低膽固醇和戒煙

D、控制糖尿病及合理飲食

E、適量運動和健康教育。Nursingnewprogress(liyuanyuan)

OralcareAspirationoforal,pharyngealsecretioninelderlypatientswithbacterialpneumoniaistheimportantfactor,andpoororalhygienecaninducethesenilepatientswithpneumonia.Prospectivestudyofelderlypatientswithgoodoralcarecanreducetheincidenceofpneumoniariskinelderly.口腔護理

誤吸口腔、咽部分泌物中的細菌是高齡老患者感染性肺炎的重要因素，而口腔衛(wèi)生較差可促使高齡老年患者并發(fā)肺炎。前瞻性研究高齡老年人做好口腔護理可降低老年人發(fā)生肺炎的危險性。InawakepatientscaughttheattentionoftheomissionofFuracilinSolution,3-4timesaday,withhighheat,lookforwardto,comapatientsdailyoralcare2times,accordingtooralpHvaluechoicegargle,PH<72%boricacidsolution,PH>7andoralmucosaulcerorpustulewithhydrogenperoxide,oralmucosahaveherpes,coatedwith2%gentianviolet.清醒患者矚其用呋喃西林溶液疏漏，3-4次每天，對高熱、瞻望、昏迷患者每天進行口腔護理2次，根據(jù)口腔PH值選擇漱口液，PH＜7時用2%硼酸溶液，PH＞7且口腔黏膜有潰瘍或膿包選用雙氧水，口腔黏膜有皰疹者，涂以2%的龍膽紫。Strengthennutritionanddietnursing:Accordingtotheelderlypatientswiththedietarycharacteristics,selectionofacceptablefood,encouragingeatinghighcalorie