Disease observation
1. Observe the degree of chest pain, cough and dyspnea of patients, and contact doctors to take corresponding measures in time.
2. Observe the patient's breathing, pulse, blood pressure and complexion changes.
3. After closed thoracic drainage, the wound should be observed for bleeding, air leakage, subcutaneous emphysema and chest pain.
Nursing measures
1. Try to avoid coughing and give cough suppressants according to the doctor's advice if necessary.
2. Reduce activities, keep the stool unobstructed, avoid holding your breath hard, and take corresponding defecation measures when necessary.
3. Patients with severe chest pain can be given corresponding painkillers according to the doctor's advice. . .
4. According to the condition, prepare articles and drugs for thoracic puncture and closed thoracic drainage, and cooperate with doctors for related treatment in time. Thoracic drainage should be carried out according to the nursing routine of thoracic drainage.
5. Give a diet with high protein and moderate crude fiber.
6. Semi-recumbent position, oxygen supply, oxygen flow rate is generally above 3L/ min.
7. Stay in bed.
health guidance
1. Diet care, eat more high-protein diet, not picky eaters, not partial eclipse, and eat crude fiber food properly.
2. After the pneumothorax is cured, avoid strenuous exercise, weight lifting or weight lifting, and hold your breath within 1 month.
3. Keep the stool unobstructed, and effective measures should be taken if the stool remains unsolved for more than 2 days.
4. Prevent upper respiratory tract infection and avoid severe cough.
Second, the nursing routine of acute upper respiratory tract infection
Disease observation
1. Pay attention to the changes of body temperature and breathing mode.
2. Pay attention to the symptoms of complications, such as headache, tinnitus and nasal swelling.
Nursing measures
1. Keep the indoor air fresh and ventilate it twice a day, each time 15-30 min. .
2. Ensure that patients have proper rest, and seriously ill or elderly people should stay in bed.
3. Drink plenty of water, the amount of water depends on the patient's body temperature, sweating and climate. Give a light and digestible diet rich in vitamins, high calories and high protein.
4. When the body temperature exceeds 38.5 degrees Celsius, give physical cooling. Use antipyretic and analgesic tablets according to the doctor's advice when you have a high fever. Observe the effect after cooling. Patients who sweat a lot should change their clothes in time and do a good job in cleaning and nursing their skin.
5. When shivering, keep warm.
6. Take the medicine according to the doctor's advice.
health guidance
1. Pay attention to respiratory isolation to prevent cross infection.
2. Maintain adequate nutrition, rest and exercise, and increase the body's resistance.
3. Avoid smoking.
4. Insist on washing your face with cold water to improve your body's adaptability to cold.
Three, pneumonia nursing routine
Disease observation
1. Measure blood pressure, temperature, pulse and breathing regularly.
2. Observe the mental symptoms, whether there is unconsciousness, lethargy and irritability.
3. Observe whether there are early symptoms of shock, such as irritability, slow response and decreased urine output.
4. Pay attention to the change of color, quality and quantity of phlegm.
5. Closely observe the effects and side effects of various drugs.
Nursing measures
1. Reasonable oxygen therapy according to the condition and doctor's advice.
2. Ensure that the intravenous infusion is unobstructed and there is no overflow, and set the central venous catheter pressure when necessary to know the blood volume.
3. Send sputum culture and blood culture according to the doctor's advice.
4. See high fever nursing routine for high fever nursing.
Chest pain, cough and expectoration can be treated symptomatically.
6. Diet care, giving a high-nutrition diet, encouraging drinking more water, and giving a light and digestible semi-liquid diet to critically ill and high fever.
7. Keep warm and stay in bed as much as possible.
health guidance
1. Exercise and strengthen the body resistance.
2. Avoid catching a cold during the season change.
3. Avoid excessive fatigue and go to public places less when a cold is prevalent.
4. Prevention and treatment of upper respiratory tract infection as soon as possible.
Four, respiratory failure nursing routine
Main points of observation
1. Consciousness, blood pressure, respiration, pulse, temperature, skin color, etc.
2. Whether there are symptoms of pulmonary encephalopathy and shock.
3. Urine volume and stool color, with or without upper gastrointestinal bleeding.
4. The effects and side effects of various drugs (especially respiratory stimulants).
5. Changes of arterial blood gas analysis and various laboratory indexes.
Nursing measures
1. Diet care, encourage patients to eat more high-protein and high-vitamin foods (patients with gastric tubes are placed according to the routine nursing of gastric tubes).
2. Keep the respiratory tract unobstructed
(1) Encourage patients to cough and expectorate, change body position and drink plenty of water.
(2) critically ill patients turn over and pat their backs every 2 ~ 3h to help expectorate. If artificial airway is established, airway management should be strengthened, and sputum aspiration should be done mechanically if necessary.
(3) Conscious people can do atomized inhalation, 2-3 times a day, each time 10-20min.
3. Rational use of oxygen Patients with type Ⅱ respiratory failure should be given continuous oxygen inhalation by nasal catheter with low concentration (25%-29%) and low flow rate (1~2L/MIN). How to use the ventilator together with the respiratory center stimulant can slightly increase the oxygen concentration.
4. Critically ill patients or those who use mechanical ventilation should make intensive care records, keep the bed flat and dry, and prevent bedsores.
5. For those who use nasal mask or nasal mask pressurization to assist mechanical ventilation, do this nursing well.
6. The establishment of artificial airway (tracheal intubation or tracheotomy) in critically ill patients should be based on the nursing requirements of artificial airway.
7. The establishment of artificial airway connected with ventilator for mechanical ventilation should meet the requirements of mechanical ventilation nursing.
8. Drug therapy
(1) Choose effective antibiotics to control respiratory tract infection according to the doctor's advice. .
(2) When using respiratory stimulants according to the doctor's advice, the respiratory tract must be kept unobstructed. Pay attention to the reaction after taking medicine to prevent overdose; For patients with irritability and insomnia at night, use sedatives with caution to prevent respiratory depression.
health education
1. Teach patients to do lip-abdomen breathing to improve ventilation. 2. Encourage patients to do proper housework and get out of bed as much as possible.
3. Prevent upper respiratory tract infection, pay attention to keep warm, go out less during the flu season and go to public places less. 4. It is recommended to quit smoking, seek medical attention for colds and control the aggravation of infection. 5. Strictly control the visits of accompanying guests and their families. Thank you. I hope you can adopt me.