內(nèi)科護(hù)理學(xué)（MedicalNursing）

1、內(nèi)科護(hù)理學(xué)(Medical Nursing)Nursing diagnosis of cough?Clearing the respiratory tract is invalid: with sputum thick, failure, expectoration, weakness relatedExercise intolerance: related to chronic frequent cough and i nadequate nutri tional intakeSleep disorders: sleep deprivation: associated with freque

2、nt cough at nightPotential compliedtion: spontaneous pneumothoraxCare for respiratory tract clearance?Environmental temperature (18-20 DEG C), humidity (50-60%), give fu11 play to the natural defense function of the respiratory tract.Diet care of high protein, high vitamins, enough calories diet, av

3、oid greasy, spicy and other stimulating foods, drinking water 1500ml every day.The condition of cough and expectoration were observed, the color, quantity and quality of sputum were recorded, and sputum specimens were col1ected correctly.Promote effective expectoration, deep breathing and effective

4、cough; inhalationtherapy; chest percussion; postural drainage; mechanical sputum aspiration;Medication, nursing, antibiotics, cough and phlegm medicine, grasp the efficacy and si de effec ts of drugs, wi tho ut abuse of drugs.Nursing diagnosis of pulmonary dyspnea:Impaired gas exchange is associated

5、 with respiratory spasm, decreased respiratory area, and ventilatory dysfunction.Exercise intolerance is associated with insufficient oxygen supply and fatigue during daily activities.Nursing measures for impaired gas exchange?Envi ronment and rest: quiet, comfortable, clean air, sui table for tempe

6、rature and humidity.Condition observation, dynamic observation, timely detection and resolution of the patient abnormalities. Monitor artcrial blood gas analysis and adjust treatment plan.Psychological care: because of bad mood can aggravate breathing difficulties, medical staff should comfort patie

7、nts, so that patients emotional stability, and enhanee confidence in treatment and security.Keep airway clearMedication, nursing, bronchodilator, antibacterial, respiratory stimulant, observe the curative effect and sideeffect.Oxygen therapy and mechanical vent i1 ation nursing, rat ional oxygen use

8、, type I respiratory failure, oxy go n in halation, type II respiratory failure, continuous low flow oxygen inhalation and oxygen inhalation equipment, regular disinfection.The standard of severe pneumonia in China?1) consciousness disorder,2) respiratory rate 30 / min.,3) Pa02 60mmHg, Pa02/Fi02 300

9、, need mechanical ventilation treatment,4) blood pressure 90/60niniHg,5) chest showed lung orinvolvement, or within 48h afteradmission of more than 50% lesion,6) oliguria: urine volume 20ml/h, or 80ml/4h or acute renal failure needs dialysis treatment.What are the measures of hyperthermia?Rest and l

10、ife care, pay attention to oral careDiet and suppl ement moisture: high cal or i e, high protein, high vitamin.Cool care: the elderly people and children with antipyretic analgesics, timely wipe.Condition observation: vital sign, hot typeMedi cat ion care: pion eer drug al lergy, quinolones nausea,

11、rash, aminoglycoside nephrotoxicityWhat are the nursing measures of septic shock?1) posture: supine, concave position2) high flow oxygen inhalation3) add blood volume, build two venous channels, correct acidosi s, record the amount of access4) medication care: the use of vasoactive drugs, drip speed

12、, maintain blood pressure, 90-100/60mmHg, improve microcirculation.5) combine broad-spectrum antibiotics to control infection, pay attention to adverse reactions and efficacy.What are the health guidelines for pneumonia?Note: prevention of skin and soft tissue infoctions, chronic disease, pay attent

13、 ion to turning back, expectoration, vacc i nationDisease knowledge: drug action, course of treatment, use, andpossible adverse reactions Fever, cough, chest pain, shortness of breath, when a sudden increase, timely treatment.What are the clinical manifestations of Streptococcus pneumoniae pneumonia

14、?Symptoms: high fever, chest pain, cough, rusty sputumSigns: mouth herpes simplex, blushing, consolidation of lung syndromeComplication: less, septic shockDuration of disease: 1-2 weeksWhat are the symptoms ofstaphylococcalpneumonia?High fever and chillsChest painPurulent sputum and (or) bloodshotPo

15、isoning symptoms, severe peripheral circulatory failure, pulmonary rales and consolidation signsHow many kinds of pulmonary abscess can bo divided into throe kinds according to different pathogeny and infection way?Inhalation pulmonary abscess is the most commonSecondary pulmonary abscessHematogenou

16、s pul mormry abscessHow does pulmonary abscess carry out postural drainage?Principle: the respiratory tract secretions are expelled from the bronchi and trachea through the action of gravityPreparation before drainageDrainage positionDrainage timeObservat i on()drai nageNursing after drainageThe eas

17、iest way to sterilize TB is to burn it directly on paperThe most important route of transmission is: droplet transmi ssionWhat are the respiratory symptoms of pulmonary tuberculosis?Cough (irritating dry cough), cough a small amount of sputum, hemoptysis, chest pain and dyspncaHow do you judge the r

18、esults of the PPD test?Methods: 0.1ml (SIU) intradermal injection, 48-72h observationdiameter of induration:(-):less than 4inm(+): 5 - 9 mm(+ +): 10 - 19min(+ + +): 220mm或局部水泡和淋巴管炎強(qiáng)陽性捉示活動(dòng)性肺結(jié)核肺結(jié)核的化學(xué)治療原則是：早期、適量、聯(lián)合、全程、規(guī)律.結(jié)核病大咯血、窒息的護(hù)理措施有哪些？1) 專人護(hù)理：及時(shí)清理血塊，漱口、避免精神過度緊張.2) 休息與臥位：大咯血絕對(duì)臥床休息，患側(cè)臥位，避免搬動(dòng).3) 保持呼吸道

19、通暢：輕輕咳出積痰跡積血，必耍時(shí)鼻腔吸痰(血 塊)，吸氧，病人不要屏氣，以避免誘發(fā)喉頭痙攣.4) 飲食護(hù)理：大咯血應(yīng)禁食，小量咯血溫流質(zhì)；避免便秘.5) 檢測(cè)病情：咯血量、生命體征注意窒息表現(xiàn)：煩躁不安、氣促、 呼吸困難、發(fā)細(xì)、而色蒼口、出冷汗；休克的表現(xiàn).6) 窒息的搶救：頭低透底腳高45度俯臥位，面部側(cè)向一邊，輕拍 背部，或直接刺激咽部以咳出與血塊.必耍時(shí)吸痰管吸引，氣管插管 或切開，高流量吸氧.7) 用藥護(hù)理：垂體后葉索，禁用于冠心病、高血壓及孕婦，緩慢靜 滴，防止出現(xiàn)惡心、便意、心悸、面色蒼白等.copd的標(biāo)志性癥狀是：氣短或呼吸困難copd嚴(yán)重程度分級(jí)的輔助檢查依據(jù)是什么？分類根據(jù)：

20、I級(jí)一IV級(jí)fevl, forced expiratory volume in the first secondfvc: forced vital capacityfvc70% fevl /最主要的條件fevl%癥狀t Kccialtot持續(xù)低流量吸氧(1 - two liters / min),每天15h以上.條件：1) pao255mmhg,或 sao2W88%2) pao2在55 - 60nimhg或sao2W88%,但存在肺動(dòng)脈高壓，心力衰 竭或紅細(xì)胞增多癥.哮喘的發(fā)病特征：夜間和凌晨發(fā)作或加重是哮喘的特征.氣流的可逆性測(cè)定和氣道反應(yīng)性測(cè)定試驗(yàn)？支氣管舒張?jiān)囼?yàn)：測(cè)沱氣流的可逆性.針対f

21、evl I .支氣管激發(fā)試驗(yàn)：測(cè)加氣道反應(yīng)性.針對(duì)緩解期，fevl在正常預(yù)計(jì)值 的70%以上者.緩解哮喘發(fā)作使川的主要舒張支氣管藥物有幾類？主耍作用是舒張支氣管卩2受體激動(dòng)劑：急性發(fā)作的首先藥物.茶堿類：氨茶堿，有效約物口服鮫安全抗膽堿藥：膽堿能山受體拮抗劑控制哮喘發(fā)作的主要藥物是？長(zhǎng)期使用機(jī)理是？糖皮質(zhì)激素控制急性發(fā)作最有效藥物.白三烯拮抗劑：抗炎和舒張平滑肌孟魯斯特其他：色甘酸鈉非糖皮質(zhì)激素抗炎藥，預(yù)防運(yùn)動(dòng)及變應(yīng)原誘發(fā)的哮 喘，肺心病失代長(zhǎng)期的臨床表現(xiàn)有哪些？呼吸衰竭 癥狀:（1）呼吸困難加重dyspnea）2）頭痛、失眠、嗜睡3）肺性腦病表現(xiàn)：精神意識(shí)異常，如淡漠、恍惚、意識(shí)喪失等體征：

22、1）紫紐（cyanosis）明顯2）球結(jié)膜水腫、充血，嚴(yán)重者顱內(nèi)高壓表現(xiàn).3）皮膚潮紅、多汗等周圍血管擴(kuò)張右心衰竭癥狀：1）明顯氣促UU I I WW I I2）心悸3）食欲不振、腹脹、惡心體征：1）頸靜脈怒張，心率増快，心律失常，劍突下可聞及收縮期雜音 2）肝大，肝頸靜脈冋流征陽性3）下肢水腫，重者可有腹水，胸水肺栓塞病因I獲得性高危因素冇哪些？長(zhǎng)時(shí)間不活動(dòng)；下肢骨折；大手術(shù)后；靜脈血栓栓塞史；惡性腫瘤;妊娠栓塞常發(fā)生于首次離床或排便后站立起來時(shí).肺栓塞的癥狀有哪些？最多見的癥狀有哪些？不明原因的呼吸困難或氣促：活動(dòng)后明顯，最多見癥狀；胸痛：胸膜炎性胸痛或心絞痛性胸痛暈厥：突然發(fā)作的-過性意

23、識(shí)喪失（唯一或首發(fā)）煩躁不安、驚恐其至瀕死感咯血：多為少量咳嗽：干咳或伴有少量白痰發(fā)熱：低熱大面積pet的主要表現(xiàn)動(dòng)脈收縮壓90mmhg,或與基線相比，下降幅度40mmhg,持續(xù)15min以上,Except for newly occurring arrhythmias, low blood volume or decreased blood pressure caused by infection.What are the common symptoms of 1 ung cancer in the early stage?Cough (irritating dry cough)Hemopt

24、ysis (bloody sputum)StridulousShortness of breathWeight loss (loss of weight, cachexia)Fever due to pneumoniaThe clinical significance of the increase of protein, LDH, ADA and CEA in pleural effusionLeakage fluid: low protein content, usually loss than 30g/L, pleural effusion protein / serum protein

25、 0. 5, mucin test (-), LDH 200U/L, hydrothorax LDH/, serum LDH 30g/L, pleural effusion protein / serum protein is usually 0. 5, mucin test (+), LDH 200U/L, pleural fluid LDH/ serum LDH 0. 6, LDH 500 U/L, suggesting tumor 1000 U/L, suggesting empyemaADA 45U/L, suggesting tuberculous pleurisyElevated

26、CEA suggests tumorThe mai n clinical manifestat ions of pleural effusion?Symptom：Dyspneo is the most common, usual ly more than 500mlChest pain is unilateralConcomitant symptoms of primary diseases are tuberculosis, tumor, pneumonia, and heart failureSigns: moderate to large, limited breathing movem

27、ents, displacement of trachea and mediastinum, knock, voiced or real sound, low respiratory soundsWhat is the appearance and cytologic differencc between the exudate and the exudate?Appearance：Leakage l iquid: transparent, cl ear, not solidified, the specific gravity is less than l018Exudate: varies

28、 in color and may have clots, with a specific gravity of 1. 018Cells：Leakage fluid: the number of cells is usually 0. 1 x 109, mainly lymphoid and mesothelial cells.Exuda te: whe n the nu mb er of cel Is is 0. 5 x 109 and whi te cel Is are predominant, i t suggests inflammation; when lymphocytes are

29、 predominant, the possibility of tuberculosis or tumor.What are the di fferent types of spontaneous pneumothorax? Which typo is the most serious?Closed (Dan Chunxing)Traffic (open type)Tension (high pressure type)What are the common symptoms of pneumothorax?Symptom：Chest pain: triggered by exertion,

30、 coughing, laughing, etc, causing a pinprick like painDyspnea：Often accompanied by chest painSevere can not lie flat or forced lateral decubitus positionEspecially large pneumothorax and tension pneumothorax, mani fested as irri tabi 1 ity, struggl ing up, nervous, dyspnea, cyanosis, cold sweat, rap

31、id pulse, shock, loss of consciousnoss and death.Cough: irritating coughSigns: pneumothorax is not obvious, there a lot of faster breathing, ipsilateral chest swelling; cyanosis, tracheal shift, rib gap widened, percussion hyperresonanee etc.Main nursing measures for patients treated with exhaust ga

32、s?Preoperative preparationInterpreta.tion workCheck whether the drainage tube is unobstructed and the tightness of the whole thoracic cavity closed drainage deviceInjocting the levelsterile saline into the water sealed bottle to markcavity atof the liquid and keep the pressure in the pleural1-2emH20

33、When negative pressure suction is needed, the negative pressure is kept at TO to -20cmH20, and a pressure regulating bottie is added between the water bottle and the negative pressure attractionEnsure effective drainageTo ensure the safety of dra in age device, to preve nt the liquid in the bottie b

34、ack into the chest.The observation of drainage tube patency: whether the water fluctuation, whether gas, when necessary to instruct patient coughThe prevention of pleural effusion or exudate obstruction of drainage tubeThe patient carefully to prevent accidents, the drainage tube vascular clamp, dra

35、inage tube to prevent slippage leakage etc.Drainage device and wound careStrict aseptic operation, the outer end of the exhaust pipe gauze bandageThe drainage fluid is changed every day, and the dra in age tube i s clamped wi th the double forceps to close to the chest cavi ty before the replacement

36、. After the replacemont is completed, the gas is released into the chest cavityDressing should be regularly checked and replacedPulmonary exerciseDeep breathingBalloon practiceMild cough promotes lung recruitmentExtubation careThere was no gas escaping in the drainage tube and 1-2 days later, the pa

37、tient was closed for 1 days without any adverse reactions- The X-ray showed that the lung had been pulled out and the tube was pulled outPay attent ion to the presence of effusion, bleedin已 and subcutaneous emphysemaWhat are the hea1th guidelines for pneumothorax?Adhere to the treatment of pulmonary

38、 underlying diseasesTo avoid pneumothorax induced by factors such as lifting heavy objects, coughing, breath, defecate; pay attention to work and rest, pneumothorax in January to avoid strenuous exercise; smoking cessationWhen once the emergency treatment of recurrent chest pain, chest tightness, sh

39、ortness of breath and feeling should be timely treatment.| | .| | |What are the categories of blood gas analysis in respiratory failure?Type I respiratory failure only hypoxia, no C02 retention, Pa02 60inmHg, PaC02 normal or lower, seen in ventilation dysfunctionType TT respiratory failure has both

40、hypoxia and C02 retention, Pa02 50mmHg, which is found in ventilation disorderWhat are the comm on clinical mani fes tat ions of respira tory fail ure?Dyspnea: acute respiratory failure for rapid breathing, three concave syndrome, chronic respi ratory fai1ure for pro!onged expiration, shallow, C02 a

41、nesthesia can have shallow breathing or slow tidal breathingCyanosisNeuropsychiatric symptoms: severe CO 2 ret ent i on manifested as pulmonary encephalopathyCirculatory system: tachycardia, circulatory failure, decreased blood pressure and cardiac arrest; CO2 retenlion can occur superficial venous

42、filling, warm sweating, pulmonary heart disease can have right heart failureThe digestive and urinary tract system is characterized by abnormal liver and kidney function, oliguria and stress ulcers in the upper gastrointestinal tractWhat are the most commonly used indicators for diagnosing ARDS?The

43、index of examination was mainly oxygenation index:Pa02/Fi02 is less than or equal to 300 for acute lung injury (ALT)PaO2/FiO2 = 200, ARDSWhat are the main nursing cooperation of trachea intubation?(1) monitoring: vital signs and hypoxia of the patient, attention to arrhythmia and aspiration.(2) oxyg

44、en supply and ventilation: simple breathing apparatus, timely artificial oxygen supply and ventilation, to prevent cardiac arrest.(3) sputum suction: excessive secretion.(4) determine the location of the trachea intubation: use a simple respirator, first auscultation of the stomach, whether there is

45、 air over the water, and then auscultation, whether or not the lungs have respiratory sounds, whether symmetrica1(5) fixation and connecting machine: after the intubation is cor rec t, in sert the tooth pad, f i x the trachea, clear the airway secretions, and then connect the ventilator to carry out

46、 mechanical ventilation.The contents of airway managoment in mechanical ventilation are briefly describedHeating and wetting of gases; sterile distilled waterSputum suetion: before inhaling sputum, high flow oxygeninhalation, 2min, not more than 15s, aseptic operation, the correct methodRespiratory

47、therapy: aerosolized medication; intratracheal instill ation of saline or distilied wat er, regular turning back.Airbag chargingTracheotomy care: daily replacement of excipients and cleaning of endotracheal tubes.Prevent accidcnts: trachea intubation or tracheotomy tube should be fixed firmly; timel

48、y dumping of water in the pipe.Life care, nasal feeding, feeding, oral care, skin care and excretory care.Psychosocial support: communicating wi th pati ents.Indications for thoracic punctureIf the pleural effusion is not clear, please take the examination of the effusion to assist the diagnosis of

49、the disease;A large number of pleural effusion or pneumothorax,Empyema or aspiration lavage in the treatment of malignant pleural effusion, required intrapleural injection of drugsTncentives for chronic heart failureInfection: respiratory tract infection is the most commonArrhythmia: atrial fibri 1

50、lationIncreased blood volume: excessive sodium intake or excessive transfusionExcessive exertion or emotional agitationPregnancy or childbirth: late pregnancy (especially twenty-eighth to 32 weeks)Other: improper treatment, the original heart disease aggravated or complicated by other diseasesThe cl

51、inical manifestation of heart failureLeft heart failureSymptoms 1, dyspnea: earlier onset and most common symptoms2, cough, expectoration, hemoptysis3, fatigue, fatigue, dizziness, palpitations: can be lost because of a rest4, oliguria and impaired renal function1. signs of pulm on ary rales: only l

52、imited to two at the bottom of the lung2. other: cardiac enlargement, apical lifting type pulsation and pulmonary valve second sound hyperfunction P2, apical diastolie gallop.3，the original signs of heart diseaseright heart failureSymptom 1. exertional dyspnea2 viscera blood stasis symptomGastrointe

53、stinal symptoms: the most common symptoms are an or exi a, bloat i ng, nausea, and vomi ting?: abdominal pain and hepatomegalyRenal congestion: decreased urine output, nocturia,proteinuria, and renal dysfunctionSigns of 1. edema: drooping, symmetry, indontation; serious patients with pleural effusio

54、n and ascites2. jugular vein engorgement or engorgement, positive sign of hepatic jugular vein regurgitation3 hepatomegaly with tenderness: cardiac cirrhosis, ascites4. cardiac signs: three, the mitral valve area can be heard systolic murmur, the expansi on of the righ t ventricle, resulting in the

55、relative insufficiency of the three cuspsHeart failure1 secondary heart failure secondary to heart failure, pulmonary congestion symptoms reduced 一 right cardiac output decreased2，loft and right ventricular failure at the same time, lung blood stasis - often not serious; cardiac bleeding related sym

56、ptoms and signsNew York Heart Association (NYHA, 1928) cardiac function classificationGrade I: physical activity is not limited, the general physical activity does not cause excessive or not adapt to the weakness, palpi talions, shortness of breath and angi naGrade II: mild physical activity is limi

57、ted, resting without discomfort, daily physical acti vity can lead to fatigue, palpitations, shortncss of breath and anginaTH: physical acti vity was 1 imi ted, rest in g without di scomfort, but less than the amount of daily activities that lead to fatigue, palpitations, shortness of breath and anginaClass IV: can not carry out any physical activities without symptoms, and may have heart failure or angina symptoms during rest. Any p