I. Overview
Case nursing report belongs to the category of data analysis, which is a type of case report and a form of academic paper. Case nursing report is a report made after summarizing the nursing work of one or several special cases (small sample, 1 case or several cases, no more than 5 cases at most). Because the case nursing report is an in-depth analysis of individual case nursing, it can explore the personality characteristics of nursing practice, summarize the experience and problems of individualized holistic nursing, and accumulate case data for studying the nursing law of a certain disease. Like nursing case analysis, case nursing report can also give readers new knowledge and new enlightenment, which has certain practical significance for promoting the development of nursing science. The main difference between case nursing report and nursing case analysis lies in the sample size, which is generally more than 100 cases.
Second, the writing format
The front and back parts of the case nursing report are the same as the standard experimental report, and the text is in a non-standard format, with 4 or 5 items often written.
(1) Front part
1 title; 2 the author; (3) abstract (abstract, about 100 words); 4 keywords; ⑤ English abstract.
(2) Body parts
1. Preface (
(1) Basis for case selection: describe whether the selected case is rare and special, and where its particularity lies.
(2) The purpose and significance of case writing.
2. Case introduction or clinical data (
The case focuses on nursing-related content, and does not talk too much about the doctor's diagnosis and treatment measures. The brief introduction of the case includes: ① the general situation of the patient; ② medical history; ③ The process and effect of medical care; 4 endings, etc.
3. Nursing (about 2000 words)
This part is the key content of nursing case writing. Nursing methods, measures and specific practices should be introduced in detail according to nursing categories, especially some innovative attempts and unique practices taken according to individual conditions to reflect the characteristics of the article. Nursing categories can be roughly divided into the following categories:
(1) treatment and nursing ① medical advice nursing (carrying out medical advice): such as medication nursing, infusion nursing, oxygen supply nursing, catheter nursing, etc. ② Symptomatic nursing: such as high fever nursing, pain nursing, cough nursing and diarrhea nursing.
(2) observation and nursing ① observation and treatment of the disease; ② Intensive care and rescue; ③ Functional monitoring and guidance; ④ Observation and nursing of wound; ⑤ Observation and nursing of complications; ⑥ Prevention and control of infection, etc.
(3) Life nursing ① Diet nursing; ② Excretion nursing; 3 skin care, etc.
(4) Rehabilitation nursing function training.
(5) Disinfection and isolation ① Disinfection at any time and terminal disinfection; (2) Infectious disease isolation and protective isolation.
(6) Psychological nursing psychological support (listening to explanations, supporting and encouraging, ensuring guidance).
(7) Health education ① Admission education; ② Hospitalization education; ③ Discharge education.
4. Discharge guidance or family rehabilitation guidance
This part can be included in the "nursing" project or not.
5. Discussion, experience or summary (
(1) The nursing characteristics of special cases are different from those of routine nursing.
(2) The main nursing problems, nursing cooperation and treatment points.
(3) Important or key nursing measures, innovative attempts, new ideas and new practices of unique nursing.
(4) The evaluation of nursing effect can be evaluated by comparing the nursing results with the expected nursing goals, or by the feedback from patients.
(5) Nursing experience, carefully summarizing the successful experience or failure lessons of nursing, and the profound enlightenment that can be left to readers.
(6) Summarize the main nursing problems, nursing measures and nursing effects.
(3) Rear part
References.
Third, the writing requirements
1. The most important principle of case selection in special case nursing report is the rarity and particularity of the case, which has the characteristics of novelty, rarity, singularity and particularity.
(1) The nursing of complicated cases is rare in clinic, and the patient's condition is complicated and changeable, so it is difficult to treat and care. But through careful treatment and nursing, it has become a successful case. Such as "1 Nursing care of children with hand, foot and mouth disease complicated with multiple organ failure" and "1 Nursing care of patients with severe incision infection and hemiplegia after hip amputation".
(2) Monitoring of critical cases, such as "1 Nursing of patients with myocardial infarction".
(3) Nursing care of rare cases.
(4) Nursing care of cases with uncommon manifestations of common diseases.
(5) Nursing care of patients with rare adverse drug reactions.
(6) Nursing with new technology, new therapy and new measures.
(7) Nursing care of misdiagnosed and mistreated cases.
(8) Nursing of the first case. Due to the lack of theoretical guidance and practical experience, there is no ready-made routine nursing measures, so it is of great practical significance to explore its nursing methods. For example, on June 6th, 2002 +065438+20021October 6th, 2002, the care of the world's first SARS patient (referred to as "SARS" in China), the care of the first avian influenza patient in 2003, the care of the first influenza A patient in 2009, and the care of the first influenza A patient in Fuyang City, Anhui Province in 2008.
2. The cases reported in case nursing should come from the cases in which nurses themselves participated in nursing. Because personally nursing, personally recording nursing medical records, familiar with cases, writing will be handy.
3. Complete data The selected cases should not only have characteristics, but also require complete nursing data records. There are complete records from admission evaluation to daily evaluation, as well as daily nursing measures and nursing results. Because writing needs not only medical information recorded by doctors, but also nursing information recorded by nurses.
4. Be familiar with the format. Be familiar with the format and requirements of case writing, and read the case report of authoritative magazines, which can be used as a model essay for your own imitation writing.
5. Highlight the unique case nursing report and introduce its unique practice in the tone of "how to do it", not just the introduction of routine nursing methods. Because of the special case, some special nursing measures are needed, and routine nursing alone can't solve the problem. The unique nursing of special cases is an innovative attempt. Introducing unique new nursing methods can highlight the characteristics of the article.
6. Effect evaluation can compare the nursing results with the expected nursing goals to evaluate the nursing effect; The effect of nursing can also be evaluated by the patient's response, so it is necessary to strengthen the interaction between nurses and patients.
7. Seriously revise "articles are never tired of changing" and "jade is uncut and abrasive". Good articles are revised repeatedly. In order to improve the quality of the paper, we should not only revise it repeatedly, but also consult experts humbly and then revise it carefully, so as to improve it continuously.
Nursing report cases
Summary 1 Nursing care of children with hand, foot and mouth disease complicated with multiple organ failure. According to the nursing difficulties of children, targeted nursing measures such as ice blanket cooling and blood vessel protection were taken. After careful nursing, the child turned the corner and recovered.
Hand, foot and mouth disease; Multiple organ failure; nurse
1 Nursing care of a child with hand, foot and mouth disease complicated with multiple organ failure Li, Jia Lili, Xie Kun
This paper summarizes the nursing care of children with hand, foot and mouth disease complicated with multiple organ failure, such as the use of ice blanket and vascular protection strategy. As a result, the child recovered well and was discharged from the hospital.
Keywords hand, food and oral diseases; Multiple organ failure; nurse
Hand, foot and mouth disease (HFMD) is an acute infectious disease caused by various enteroviruses, including Cosac virus A 16 and enterovirus 7 1 (EV7 1). Most children have rashes and herpes on hands, feet and mouth, and most of them have a good prognosis. However, a few children can show serious damage to the central nervous system, causing neurogenic pulmonary edema, aseptic meningitis, acute flaccid paralysis and so on. Rapid progress and high mortality. In April 2008, hand, foot and mouth disease (HFMD) caused by EV7 1 enterovirus occurred in Fuyang City and its surrounding areas, Anhui Province. The epidemic spread widely, with many severe cases and many deaths in a short time. From May 5 to June 5, 2008, the medical team of our hospital rushed to the People's Hospital of Bozhou City, Anhui Province to guide the treatment and help control the epidemic and the mortality rate was controlled. On May 8-29, 1 case of hand, foot and mouth disease complicated with multiple organ failure was successfully treated. The nursing experience is reported as follows:
Clinical data of 1
Baby boy, 15 months. On May 8, 2008, he was admitted to the hospital for hand, foot and mouth disease (phase II). In order to control the disease, high-dose gamma globulin was immediately used to regulate immune function and high-dose methylprednisolone pulse therapy, combined with comprehensive treatment such as lowering skull and blood pressure, antivirus and antipyretic. 10 In the early morning of May, the child's condition became worse, his limbs were cold, his blood pressure was169/93 mmhg (1mmhg = 0.133 kpa), he was unconscious, and he breathed in tidal mode, and a large amount of pink foamed sputum gushed out of his mouth, and a large amount of brown liquid was drained by inserting a gastric tube. Immediately enter the intensive care unit for rescue, and give mechanical ventilation and ECG monitoring. On may 14, the child's consciousness gradually became clear, and there was a cough reflex after stimulation. Repeated blood gas analysis showed that the child's breathing was stable, his blood pressure and heart rate were stable, and his oxygen saturation was above 95%. Unplug tracheal intubation and inhale oxygen through nasal catheter. On May 2 1 day, the child's condition was stable and he was transferred from the intensive care unit to the general ward. After 1 week of continuous observation and treatment, she recovered and was discharged.
2 nursing
2. 1 closely observe the changes of the disease and accurately record the amount of entry and exit.
Although timely and effective treatment measures were taken after admission, the case still developed rapidly, and it progressed to the third stage of hand, foot and mouth disease (cardiopulmonary failure stage) 2 days after admission. In view of this situation, closely observe the changes of children's condition and accurately record the amount of access: ① Closely monitor vital signs, monitor the children's temperature, respiration, heart rate, blood pressure, oxygen saturation, peripheral circulation and blood sugar every half hour, 1 time /2h. The child's condition has developed rapidly and made rapid progress. After entering the intensive care unit, give one-on-one special care, closely observe the changes of the child's condition at all stages, and report to the doctor at any time. When the child has symptoms of respiratory and circulatory failure, we report to the doctor in time and cooperate with the treatment to win time for successful treatment. (2) Accurately record the inflow and outflow, limit the inflow of liquid, achieve the inflow and outflow balance, and reduce the cardiopulmonary load. Strictly control the infusion speed with the infusion pump, and record the infusion volume, dosage and the amount of urine and feces of the children in detail. Statistical comparison of each hour 1 time, notify the doctor in time if there is any change, and adjust the infusion volume and speed according to the doctor's advice. Due to the strict implementation of the principle of balance in and out, although the child used more drugs in the rescue, it did not cause adverse injuries, which laid a good foundation for the later rehabilitation. ③ Monitor blood gas regularly, report the results of blood gas analysis to the doctor in time, and adjust the ventilator parameters at any time according to the doctor's advice.
2.2 Tracheal management
Two days after admission, the child developed multiple organ failures such as heart, lung, brain and digestive system. It is characterized by cold limbs, high blood pressure, unconsciousness, tidal breathing, more pink foam-like sputum spewing out of the mouth, and a large amount of brown liquid drained from the stomach tube, which is dying. Good airway management: ① Quick intubation and mechanical ventilation. 1 week, when the sputum of children is sticky, chymotrypsin is inhaled twice a day to dilute the sputum and make it easy to be sucked out, while keeping the airway moist to avoid irritating dry cough. ② Keep the airway of mouth, nose and pharynx unobstructed: Use cotton swab dipped in warm water to remove the secretions of mouth, nose and throat of children, four times a day. (3) Suction of sputum according to the procedure: If there is too much sputum, clean the respiratory secretions according to the procedure of sputum suction-humidification-sputum suction [1], so as to achieve sufficient sputum suction every time, with the negative pressure not exceeding 80mmHg and the sputum suction time not exceeding 15s. Pure oxygen inhalation 1-2min and airway humidification 1 time were given before and after sputum aspiration.
2.3 High fever nursing
The child had a low fever five days before admission, and his mental state was poor. His body temperature continued to rise to about 39℃ two days after admission. After physical cooling with drugs and ice packs, his temperature was still high, and he lost consciousness two days later. Therefore, it is necessary to carry out hyperthermia care for children: ① cooling to prevent febrile convulsions, protecting the brain and preventing brain hypoxia; Use an ice blanket to cool down. Before using the ice blanket, check whether the performance of the electric ice blanket is good, and then lay the ice blanket under the sheets. The child's body below the neck is on the ice blanket. Don't touch the neck to avoid bradycardia caused by parasympathetic nerve excitement. Connect the power cord and water guide pipe correctly, and put a proper amount of distilled water in the water tank. In order to continuously monitor the body temperature, prevent the sensor probe from falling off and avoid cross infection, the anal temperature sensor probe was wrapped with disposable finger cuff and properly fixed on the inner thigh. The cooling speed of the ice blanket should not be too fast, and it is appropriate to cool down 1.0- 1.5℃ every hour, reach the therapeutic temperature within 3-4 hours, and control the anal temperature at about 36℃ [2]. ② Pay attention to the children's heart rate, blood pressure, urine output and limb circulation during the ice blanket cooling. When children are found cyanosis and cold limbs, properly adjust the temperature of the high blanket and put a hot water bottle under their feet. Measure the body temperature 1 time every half hour and compare it with the temperature of the ice blanket, observe the cooling effect at any time and make records [3]. 3 After cooling, the child sweats a lot, and changes clothes and sheets in time to avoid catching cold and increase comfort.
2.4 infusion management
During the rescue, the children used a lot of anti-infection, blood pressure lowering and electrolyte supplementing drugs every day. In addition, they also used high permeability drugs such as mannitol and glycerol fructose, which increased the difficulty of venipuncture and vascular protection. Therefore, it is necessary to do a good job in infusion management: ① vein selection: We choose flexible and thick parts for venipuncture, and adopt alternate injection methods, such as alternate use of left and right upper limb veins, to repair damaged veins. ② Vascular protection: Four hours after infusion of hypertonic drugs such as mannitol, glycerol and fructose, the child should apply a hot towel at about 40℃ to prevent burns [4]. In addition, when the child's body temperature is controlled at about 36℃, we also apply the method of dropping temperature solution [4]. According to literature report [5], the lowest temperature of intravenous infusion is 65438 05℃, and the highest temperature is 35℃. When the liquid is kept at the lowest temperature, the probability of phlebitis is higher, the children's conscious symptoms are heavier, and the number of blood vessel use is reduced. Therefore, according to the physical and chemical properties of therapeutic drugs and children's feelings, we adjust the liquid temperature to 25-35℃. ③ Observation and nursing of drug action: When using infusion pump to inject sodium nitroprusside injection, you should observe the use requirements, pay attention to avoid light, and observe whether the actual dose is equal to the target dose. When there are errors, it is necessary to monitor blood pressure in time and report to the doctor for adjustment. High dose methylprednisolone can cause infection, hypertension, gastrointestinal bleeding and other adverse reactions. Therefore, disinfection and isolation should be done well, the changes of children's condition should be closely observed, and whether there are adverse drug reactions should be judged as soon as possible to avoid cross-infection of children.
2.5 Disinfection and isolation
Hand, foot and mouth disease is spread by enterovirus and highly contagious. Children's saliva, sputum, gastric juice, urine and feces are infectious, so it is very important to do disinfection and isolation. ① The ultraviolet circulating machine disinfects the air every morning and evening 1 time for 30 minutes each time. ② The secretions, vomitus and excreta of children were treated with 3% bleach solution for 2 hours, and then poured into the sewer. ③ All medical staff who have come into contact with children should wash their hands strictly to prevent cross infection. ④ Disinfect children's daily necessities and tableware with 0.5%- 1.0% chloramine solution; Children's clothes are soaked in 500mg/L chlorine-containing disinfectant for 30 minutes and then washed. Children's sheets are sent to the laundry room for separate cleaning and disinfection [6].
3 discussion
In this case, the child entered the second stage of hand, foot and mouth disease when he was admitted to hospital, and quickly entered the third stage two days later, with multiple organ failure, which was a great challenge to medical staff. The focus of treatment is to protect the functions of heart, lung and brain. Nursing should cooperate with the treatment point, strengthen the maintenance and management of mechanical ventilation, closely observe the changes of children's condition, protect veins, and rationally use modern nursing instruments, such as ice blanket cooling and ultraviolet circulating air disinfection. In this case, the cooling blanket plays an important role in body temperature regulation. Initially, children used ice packs to physically cool their foreheads and aorta. Because the contact area between the ice pack and the body surface is small and the cooling speed is slow, the cooling effect cannot be achieved. After using the cooling blanket, it is not only convenient and labor-saving, but also has a definite cooling effect and quickly reaches the temperature required for treatment. In addition, the child's fever is repeated. The cooling blanket can well regulate the changes of children's body temperature and control the anal temperature at about 36℃, which plays an important role in reducing brain oxygen consumption and preventing febrile convulsions.
refer to
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[2] Chen Shaowen. Nursing experience of electric ice blanket applied to central high fever [J]. Journal of Nurse Training, 2007,22 (4a): 661.
[3] ten thousand. Clinical observation and nursing care of medical electric ice blanket in the treatment of central high fever [J]. Journal of Clinical Medical Practice: Nursing Edition, 2007, 2: 38.
Lu Yuquan. Prevention and nursing of phlebitis [J]. China Journal of Practical Nursing, 2004,20 (5a): 62-63.
Wu Miaoling. Research progress in nursing care of chemotherapy-induced phlebitis and leakage injury [J]. China Journal of Practical Nursing, 2000, 16 (7): 4.
Hao Huijie, Gao. Nursing care of children with hand-foot-mouth disease [J]. Journal of Practical Medicine, 2008,25 (a): 207.