Dependent nursing measures: measures implemented according to doctor's advice.

Cooperative nursing measures: measures taken by nurses in cooperation with other medical personnel.

Independent nursing measures: measures put forward and taken independently by nurses without relying on doctor's advice. Including: assisting patients to complete daily self-care activities; Treatment measures; Observation of diseases and psychological activities; Health education and consultation; Provide psychological support; Make a discharge plan, etc.

Matters needing attention in formulating nursing measures: nursing measures should be targeted. Nursing measures should be practical. Nursing measures should be consistent with other medical personnel. Nursing measures should have scientific basis. Nursing measures should be specific, executable and operable.

Common nursing measures:

1, pain and surgical trauma or trauma, etc. ：

Use good hints to eliminate pain, let patients relax and eliminate tension. Pay attention to patients with chronic pain and create a positive and happy environment and mood. Understand the pain of patients, treat patients as relatives, and solve problems for patients. Do not actively encourage and care about patients' inappropriate pain manifestations, and help patients cultivate healthy and beneficial behaviors. Use analgesics appropriately according to the doctor's advice.

2. Asphyxia may be related to insufficient humidification, untimely sputum aspiration, sputum scab blockage, laryngeal spasm, etc.

Correctly judge the cause of suffocation and deal with it. Prepare a central negative pressure sputum suction device or an electric sputum suction device and related rescue items at the bedside. All patients with tracheotomy or tracheal intubation should fully moisten the airway to prevent the formation of sputum scab. Suction of sputum in time and moderate negative pressure are correct. When inserting a gastric tube, the conventional length of the gastric tube is further extended by 7 ~ 10 mm, so that the front end of the gastric tube is located at the stomach body or pylorus, which can effectively decompress the gastrointestinal tract and prevent the injected food from flowing back.

The best posture to reduce reflux is to set the bedside angle to semi-recumbent position ≥ 30 during nasal feeding. Keep this posture for 30 ~ 60 min after nasal feeding, and then return to the original position to prevent accidents.