Inefficient breathing pattern
[Related factors]
1. Respiratory myasthenia.
2. Neuromuscular participation.
3. lack of oxygen.
[Main performance]
Breathe shallow and slowly.
The lips, skin and mucous membrane are cyanotic, and the nose is restless.
Cough and expectoration.
Breathing is obviously concave.
Blood gas analysis showed that the partial pressure of oxygen was normal or the partial pressure of carbon dioxide was higher than normal.
[nursing goal]
The patient can maintain a good breathing state, without dyspnea and cyanosis, and the arterial blood gas analysis value is normal.
Patients can maintain the best breathing pattern and reduce dyspnea.
[Nursing measures]
Raising the bedside is good for breathing.
Keep the oxygen pipeline unobstructed.
Encourage patients to cough, take a deep breath and suck sputum if necessary.
Accompany patients with acute dyspnea to make them feel safe, so as to reduce anxiety and fear and help them breathe.
Wear loose and soft clothes to avoid affecting breathing.
Observe the patient's breathing frequency, rhythm and depth. If you find that breathing is strenuous, breathing is slow, coughing is weak, and swallowing is difficult, you should prepare tracheal intubation and mechanical ventilation equipment and be ready to cooperate with the rescue at any time.
Cooperate with the doctor for tracheotomy when necessary.
After tracheotomy, the skin around the incision should be strictly disinfected and the wound gauze should be replaced in time to prevent infection.
Disinfect the endotracheal tube 4 times a day.
Cooperate with the doctor to check the blood analysis regularly and observe whether the hypoxia situation has improved.
Patrol should be strengthened and help should be given when necessary.
[Critical Assessment]
Whether the patient's hypoxia and dyspnea have been improved; Whether the degree of cyanosis of skin mucosa and lips is reduced or disappeared; Whether alar tremor and concave sign disappear.
Monitoring arterial blood gas analysis value; Whether the patient can maintain a good breathing state.
Whether effective measures can be taken to cough and expectorate.
Suction ineffectiveness
[Related factors]
1. Increased secretion caused by lung infection.
2. Cough weakness or fatigue.
3. Consciousness disorder, cognitive disorder.
[Main performance]
Breathing sounds are thick, breathing is shallow and fast, accompanied by nasal wing agitation and three concave signs.
Respiratory secretions, cough, expectoration.
Cough weakness, unable to cough up phlegm effectively.
Because of breathing difficulties, use an auxiliary ventilator.
Arterial blood gas analysis showed that oxygen partial pressure was low and carbon dioxide partial pressure was high.
【 Objective 】 To keep the patient's respiratory tract unobstructed, characterized by clear breathing sounds and normal breathing, effective expectoration and deep breathing after treatment.
Keep the indoor air fresh, ventilate twice a day for 15∽30 minutes each time, and keep warm.
Keep the room temperature at 18∽22℃ and the temperature at 50%∽70% (spray water indoors when the air is dry).
If the patient has purring sputum, encourage the patient to cough, guide the patient to effectively expel sputum, and give negative pressure sputum suction if necessary.
Instruct patients to perform postural drainage, help patients turn over and pat their backs before expectoration, and pat their backs from top to bottom and from outside to inside.
Use antibiotics according to the doctor's advice, and pay attention to the efficacy and side effects of drugs.
According to the doctor's advice, give atomized inhalation and oxygen inhalation, dilute sputum and diminish inflammation.
Encourage drinking more water within the tolerance of the heart.
[Critical Assessment]
Whether the respiratory tract is unobstructed.
Whether it can effectively cough up phlegm.
Whether the breathing condition has improved, whether there is dyspnea and the use of auxiliary ventilator.
Third, physical activity disorder.
[Related factors]
Tetraplegia.
Neuromuscular involvement.
Consciousness disorder.
[Main performance]
Paralysis of limbs, loss of motor function of limbs.
The patient's self-care ability is reduced, and he can't carry out daily activities, such as walking, dressing, eating, washing his face and combing his hair.
[nursing goal]
The patient's living needs are met during his stay in bed.
With help, patients can do some activities, such as walking and getting dressed.
Patients reach the best level of self-care, such as eating and combing their hair.
[Nursing measures]
Assess the mobility of the affected limb and make a nursing plan with the patient.
Put the affected limb in a functional position to prevent sequelae such as foot drop and claw-shaped hand.
Instruct patients to actively exercise their affected limbs and encourage them to achieve results.
Assist and urge patients to carry out functional exercise in time, according to the condition, according to the order of passive exercise in bed → active activity in bed → bedside activity → getting out of bed activity, with moderate intensity, step by step and perseverance. The range of passive motion is from small to large, from big joints to small joints; Massage should be done in a gentle and slow way.
Methods of teaching patients' families and their companions to exercise.
Activities need to be accompanied in case of injury.
Cooperate with acupuncture and physiotherapy to promote the recovery of limb function.
Encourage patients to take care of themselves to meet the needs of returning to family and society.
[Critical Assessment]
Whether the patient's ability of daily living is improved.
Whether the patient is safe and injured during the activity.
Fourth, the integrity of the skin is damaged: there is the possibility of bedsore.
[Related factors]
Tetraplegia.
Stay in bed for a long time
Insufficient nutrition.
[Main performance]
Dry skin, poor elasticity, easy to break.
Long-term compression, redness and reactive hyperemia of local skin.
Sweating a lot makes your skin wet.
Malnutrition, poor skin elasticity, and less subcutaneous fat at bony processes.
[nursing goal]
No bedsores.
The patient feels clean and comfortable.
[Nursing measures]
Turn over the patient every 2 hours 1 time, massage the compressed part of the local bone protuberance, and pay attention to avoid pushing, pulling and dragging when turning over to avoid rubbing the skin.
Sleep in an air cushion bed, and put a soft pillow or rubber band on the bone protrusion to reduce local compression.
Keep the plate clean, dry, flat and free of slag. Sweat for a long time, scrub in time and change into clean clothes and pants.
Pay attention to a reasonable diet, strengthen nutrition and enhance resistance.
Soak your feet with hot water and take a bath with warm water every day to promote blood circulation.
[Critical Assessment]
Whether bedsore occurs.
Does the patient feel clean and comfortable?
Verb (abbreviation for verb) changes in perception.
[Related factors]
Demyelinating lesion of peripheral nerve.
Sensory conduction pathway is damaged.
【 Main manifestations 】 It is characterized by hypoesthesia at the distal extremities, such as feeling like wearing gloves and socks.
[nursing goal]
The patient was not injured.
Promote consciousness to return to normal.
[Nursing measures]
Scrub body parts with warm water every day to promote blood circulation and sensory recovery.
Keep the bed clean, dry and free of sundries, so as to avoid damage to the body parts with sensory impairment.
Pay attention to keep the patient's limbs warm, but when using hot water bottles, the water temperature should not exceed 50℃ to prevent burns.
Give physical massage and passive exercise.
Help turn over. 1 Once every 2 hours, do a good job of regular massage, regular replacement, regular cleaning and regular scrubbing to prevent bedsores.
Patients are often trained in perception, such as using paper and wool to stimulate shallow touch, warm water to stimulate temperature perception, and acupuncture to stimulate pain.
[Critical Assessment]
Whether the factors causing the patient's injury have been ruled out.
Whether the patient's consciousness is gradually restored.
Six, self-care defects
[Related factors]
Tetraplegia.
Consciousness disorder.
Physical exhaustion and weakness.
[Main performance]
Can't do activities of daily life, such as eating, dressing, grooming, bathing, going to the toilet and getting out of bed.
Dependence is enhanced.
Perceptual impairment.
[nursing goal]
Patients feel clean and comfortable when resting in bed, and their living needs are met.
Patients can take care of themselves, such as combing their hair, washing their faces, going to the toilet and dressing.
The patient basically recovered to the original level of self-care in daily life.
[Nursing measures]
Encourage patients to take care of themselves.
Put the items commonly used by patients in an easy-to-get place so that patients can take them at any time.
The signal light is placed at the patient's hand. When you hear the bell ring, answer it at once.
Assist patients in dressing, grooming, hygiene, bathing, going to the toilet and eating during bed rest.
Instruct patients to wear loose and soft clothes and shoes without shoelaces.
Patients need to be accompanied when going out to prevent accidental injuries.
[Critical Assessment]
Whether the patient's living needs are met and whether the bed unit is clean and comfortable.
Whether the patient can fully recover the self-care ability of daily life and what self-care activities can be carried out.
Seven, fear
[Related factors]
Dyspnea, a sense of near death.
Sports strength has plummeted.
Health status changes.
Afraid of tracheotomy.
[Main performance]
There is panic, fear and anxiety in private prosecution.
There are crying and refusal behaviors.
Sensitive and suspicious.
Rapid heartbeat, shortness of breath, flushing or pallor of skin, sweating, irritability, insomnia and dreaminess.
[nursing goal]
The patient's fear is reduced, and the behavior and signs of fear are reduced.
The patient can describe the psychological feeling of fear.
Patients can take positive coping styles to fight their fears.
[Nursing measures]
Understand patients' fears, encourage patients to express their feelings, and patiently listen to the reasons for patients' fears.
Patiently explain the process, treatment and prognosis of the disease to patients, and encourage patients to establish confidence in overcoming the disease.
Patiently guide patients to improve their breathing methods and reduce their sense of dying.
Before cooperating with doctors for tracheotomy, we should do a good job in explaining the patients and eliminate their panic and fear.
Instruct patients to use relaxation techniques, such as slow and deep breathing, whole body muscle relaxation, listening to light music, etc.
Try to avoid contact with rescued or critically ill patients.
Family members participate in efforts to alleviate patients' fears, such as companionship, distracting conversation and appropriate massage.
Give positive encouragement to the patient's progress in time.