1. Medical history Ask about the medical history, whether there were repeated respiratory infections in the past, and find out whether there were primary diseases such as measles and whooping cough before the onset. Whether there is a history of premature delivery and suffocation at birth, whether family members have a history of respiratory diseases, and the growth and development of children.

2. Physical and mental status check whether the child has symptoms and signs such as shortness of breath, sitting breathing, tangy nose, depression around the lips, cyanosis, fever, cough, expectoration, tachycardia, lung rales, and clinical manifestations of circulatory, nervous and digestive system involvement.

Understand the psychological status of children and parents, whether they have anxiety and fear, whether their children have been hospitalized in the past, and how the family economy is.

3. Auxiliary examination to understand the chest X-ray results, etiology and peripheral white blood cells.

Common nursing diagnosis:

1. Impaired gas exchange is related to lung inflammation.

2. The ineffectiveness of clearing the respiratory tract is related to excessive respiratory secretions, sticky sputum and inability to discharge phlegm.

3. Hyperthermia is related to infection.

4. Potential complications

(1) Heart failure: It is related to pulmonary hypertension and toxic myocarditis.

(2) Toxic encephalopathy: related to hypoxia and carbon dioxide storage.

(3) Toxic enteroparalysis: related to toxemia and severe hypoxia.

Expected goal:

1. The symptoms of shortness of breath and cyanosis disappeared, and the breathing was stable.

2. It can successfully and effectively cough up sputum, and the cough intensity is weakened and the pain is relieved.

3. Body temperature and other vital signs return to normal.

4. No complications occurred during hospitalization.

Nursing measures:

1. Adjustment of environment: keep the ward comfortable, with good air circulation and proper temperature and humidity, and try to keep the children quiet to reduce oxygen demand. Use antibiotics according to the doctor's advice and observe the treatment effect.

2, oxygen therapy oxygen therapy is helpful to improve hypoxemia, shortness of breath, cyanosis children should be given oxygen and evaluate the therapeutic effect and record.

3. Keep the respiratory tract unobstructed, closely monitor vital signs and respiratory distress, and help to understand the development of the disease; Help children to take the correct posture, raise the bedside by 30o-60 "to facilitate respiratory movement and discharge of upper respiratory secretions, and encourage children to lie on their side to relieve pain and reduce cough; Help clear respiratory secretions, guide children to cough effectively, and help to change posture before expectoration. You can pat your back with your fingers together, slightly inward, from bottom to top, and from outside to inside to encourage your child to cough while patting. Through gravity and vibration, the secretions of alveoli and respiratory tract can be easily discharged, and inhalation therapy and postural drainage can make sputum thinner and easier to cough up.

4. Care for fever Corresponding cooling measures should be taken for fever (see Section 2 of this chapter, "Nursing for High Fever"). Fever can accelerate metabolism, increase oxygen consumption and aggravate hypoxia, so we should monitor body temperature and be alert to the occurrence of febrile convulsion.

5. Nutrition and water supplement encourage children to eat a high-calorie and high-protein diet and drink plenty of water. Protein and insufficient calories will affect the recovery of the disease. Intake of enough water can ensure the moistening of respiratory mucosa and the repair of mucosal lesions, increase the ciliary movement ability, prevent secretions from drying up, and be beneficial to the discharge of sputum. At the same time, it can prevent dehydration caused by high temperature. On the other hand, the drip rate of liquid should be strictly controlled during intravenous infusion, and it is best to use infusion pump to maintain uniform drip. Severe children should accurately record the 24-hour inflow and outflow.

6. Closely observe the condition, find problems in time, and assist doctors to deal with them together. ① If the child is fidgety, pale and breathless, his heart rate is accelerated (> 160- 180 beats/min), and his liver increases sharply for a short time, all these are manifestations of heart failure. This is due to the reflex contraction of pulmonary arterioles caused by hypoxia and carbon dioxide retention, which leads to pulmonary hypertension and toxic myocarditis. It is necessary to report to the doctor in time, slow down the infusion speed, and prepare cardiotonic diuretics for timely application. If the child's spitting pink foam sputum is the manifestation of pulmonary edema, the child can be inhaled with oxygen humidified with 20% ~ 30% ethanol, which can reduce the surface tension of alveolar foam, make the foam rupture and dissipate, improve gas exchange, and quickly relieve the symptoms of hypoxia. But each inhalation should not exceed 20 minutes. ② Because pathogen toxin, toxic encephalopathy, hypoxia and carbon dioxide storage can dilate cerebral capillaries and increase the permeability of blood-brain barrier, which can lead to brain edema, we should closely observe mental state, pupil changes and muscle tension. If there are symptoms of intracranial hypertension such as irritability or lethargy, convulsion, coma, irregular breathing and increased muscle tension, we should immediately rescue them together with doctors. ③ Observe whether there is abdominal distension, whether the bowel sounds weaken or disappear, and whether there is blood in the stool, so as to find toxic intestinal paralysis in time.

7. Health education guides children to strengthen nutrition and physique. Eat a high-protein and high-vitamin diet, do outdoor activities, do physical exercise, especially strengthen respiratory exercise and improve respiratory function. Teach your child to cover his mouth with a handkerchief or paper when coughing, and try not to spray sputum drops around. Don't spit everywhere to prevent bacteria from polluting the air and infecting others. Children who are prone to respiratory infection should keep warm when they go out in cold season or when the climate changes suddenly to avoid catching a cold. Let parents know about breathing

The name, dosage, usage and common adverse reactions of commonly used drugs for road infection enable the disease to be treated in time at an early stage.

Nursing evaluation: whether the symptoms and signs of shortness of breath in children gradually improve or disappear; Whether the respiratory tract is kept unobstructed and whether the doctor can expectorate effectively; Whether the vital signs such as body temperature gradually return to normal; Whether to prevent complications.