2022年2022年护理实践护理诊断 .pdf

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1、呼吸 whats up W -where is it? 在哪H -how does it feel? 感觉怎样A -aggravating and alleviating factors 加重和减轻的因素T timing 时间S severity 严重程度U -useful other data 其他有用信息P - patient s perception of the problem病人主观感受消化系统 Nursing process of patients with upper respiratory tract disorders 上呼吸道疾病患者的护理过程1 Acute pain re

2、lated to gastric mucosal erosion急性疼痛与胃黏膜受侵蚀有关（1）ask patient to rate pain level on scale of 0 to 10 every 3hours and as needed （2）ask about for factors precipitating and relieving pain （3）ask patient to help identify techniques for pain relief （4）adm inister antiulcer medications as ordered （5）provid

3、e sm all ， frequent m eals 4 to 6 times a day （6）encourage nonacidic fluids between meals2 Risk for injury related to complications of peptic ulcer activity such as hemorrhage and perforation有受伤的危险与消化性溃疡活动引起的出血穿孔等并发症有关（1）monitor for signs and symptom s of hemorrhage such as henmatemesis and melena （

4、2）monitor vital signs：blood pressure，pulse ，respirations，and tem perature （3）maintain intravenous infusion as ordered （4）monitor hematocrit and hemoglobin levels as ordered 心血管系统Nursing process of patients with hypertension 1.Deficint Knowledge related to disease process and treatment regimen.知识缺乏与不

5、了解疾病病程和治疗方案有关(1) Identify patients readiness and ability.(2) Provide patient with information concerning disease process including risk factors ,complications , and treatment regimen. 2.Potential for ineffective therapeutic regimen m anagement related to complexity of therapy , cost of medications ,

6、 lack of symptom s, side effects of medications , need to after long-term lifestyle habits , normal blood pressure controlled by therapy. 潜在的对治疗方案管理无效与治疗复杂性，药物开销 ，缺乏症状 ，药物副作用 ，需要调整长期生活方式，经治疗后血压正常有关。(1)Identify patients modifiable risk factors and lifestyle modification needs.(2)Identify factors that

7、 are barriers to patient complying with therapy. (3)Develop plan to overcome barriers. Make referrals as needed. (4)Assess ability to take medications daily : financially , obtaining refills , understanding directions. (5)Teach patient take medications as prescribed and not to skip dosages. (6)Teach

8、 patient to change positions slowly to prevent falls. 名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - - - - - - 第 1 页，共 3 页 - - - - - - - - - 呼吸系统 nursing care plan for the patient with a lower respiratory tract disorder 1.Impaired gas exchange related to decreased ventilation or

9、 perfusion. 气体交换受损与通风减少或灌注有关(1) Assess lung sounds, respiratory rate and accessory muscles. (2)Observe skin and mucous membranes for cyanosis. (3)Assess degree of dyspnea on a scale of 0 to 10,0=no dyspnea，10=worst dyspnea (4) Monitor for confusion or changes in mental status. (5)Monitor arterial bl

10、ood gas values and pulse oximetry as ordered. (6)Elevate head of bed or help patient to lean on overbed table. (7)Position with good lung dependent“good lung down ” (8)Adm inister supplemental oxygen at 2L/min unless ordered otherwise. (9)Place a fan in the patients room.2.Ineffective airway clearan

11、ce related to excessive secretions. 清理呼吸道无效(1)Assess lung sounds q4th and prn (2)Monitor amount, color, and consistency of sputum. (3)Encourage oral fluids; use cool steam room humidifier. (4)Turn patient q2h or encourage to ambulate if able. (5)Encourage patient to cough and deep breathe every hour

12、 and prn. (6)Adm inister expectorants as orders. (7)If patients unable to cough up secretions, suction per instruction policy (8)Obtain order for chest physiotherapy or flutter valve if indicated. 3. Ineffective breathing pattern related to anxiety and pain.低效性呼吸形态与焦虑疼痛有关(1)Assess respiratory rate,d

13、epth,and effort q4h and prn. (2)Monitor blood gas and oxygen saturation values. (3)Determ ine and treat the cause of ineffective breathing pattern. (4)Place patient in Fowler s or sem i- Fowler s Position. (5)Teach patient ito use diaphragmatic breathing,with a regular 2 second in,4 second out patte

14、rn 4.Activity intolerance related to imbalance between oxygen supply and demand活动无耐力与供氧和需氧不平衡有关(1)Assess amount of activity the patient can tolerate without becoming short of breath. (2) Monitor vital signs and oxygen saturation with activities. (3)Allow patient to rest between activities. Bed rest

15、may be necessary during the acute dyspnea. (4)Obtain bedside commod,shower chair,handheld showerhead if needed。(5)Obtain portable oxygen if patient is able to ambulate 。(6)Allow uninterrupted rest night as much as possible。(7)Slowly increase activity as able. (8)Refer patient with chronic lung disea

16、se to a pulmonary rehabilitation program 泌尿系统 ：nursing care plan for the patient with renal failure 1.nursing diagnosis：excess fluid volume related to kidneys inability to excrete water.体液过多与肾脏不能把水排出有关(1) monitor weight daily at same time; report gain of greater than 2 pounds, monitor intake and out

17、put. (2) monitor and report shortness of breath, tachycardia, cackles in lungs, frothy sputum, heart 名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - - - - - - 第 2 页，共 3 页 - - - - - - - - - irregularities, hypotension, cold clammy skin. (3)watch for new onset of jugular vein diste

18、ntion with patients head raised to 30- to 45- degree angle. (4). monitor vital signs, including orthostatic blood pressure.(5).monitor for edema. (6).monitor activity tolerance.(7).monitor serum protein and albumin levels. (8).maintain sodium and fluid restrictions as ordered. (9).develop a plan wit

19、h specific allotted amounts of fluid at each meal and for medications. Teach patient importance of each. 2.im paired skin integrity related to dryness，excess fluid ，crystal deposits 皮肤完整性受损与干燥、多余的体液 、晶体存储有关(1).served skin for open areas and signs of infection. (2).bathe with tepid water,oils or oatm

20、eal. (3).apply lotion to skin after bathing. 3.Activity intolerance related to anemia secondary to impaired synthesis of erythropoietin by the kidneys. 活动无耐力与肾脏红细胞生成素受损而引起的继发性贫血有关。(1).assess for pale mucous m embranes and skin color, dyspnea，chest pain. (2).monitor hemoglobin, hematocrit。(3).watch f

21、or signs of bleeding。(4).administer erythropoietin as ordered.assist with blood transfusion as necessary.协助输血(5.have patient space activities with rest periods. 4.Risk for injury related to bleeding tendency from platelet dysfunction and use of heparin during dialysis, and tendency for gastrointesti

22、nal bleeding。有受伤的风险与由于血小板功能障碍、在透析中使用肝素和消化道出血引起的出血倾向有关。5.risk for infection related to impaired immune system function 有感染的危险与免疫系统功能受损有关（1） monitor for signs and symptom s of infection and report promptly to physician （2）protect patient from any source of infection, including infected roommates, visi

23、tors, or nursing staff （3） maintain skin integrity （4）staff and patient practice good hand washing technique （5）culture any suspected site of infection as ordered by physician （6）consult with physician about influenza and pneumonia vaccines （7） teach patient and family signs and symptom s of infecti

24、on to report to physician 6.Imbalanced nutrition,less than body requirements related to restricted diet,anorexia,nausea,and vom iting,and stomatitis secondary to effect of excessive urea on the gastrointestinal system 营养失调 ，低于机体需要量与饮食限制，食欲减退 ，恶心 ，呕吐和继发于胃肠系统的尿素氨的口腔炎有关（1）Monitor weekly weight and seru

25、m protein and albumin levels. （2）Consult diet planning and teaching. （3）Initiate a calorie countconsult dietitian for assistance. （4）Provide frequent oral care. （5）Offer frequent small feedings and dietary supplements. （6）Offer medications ordered for nausea before meals. （7）Ensure bowel movement daily or according to patients usual pattern.名师资料总结 - - -精品资料欢迎下载 - - - - - - - - - - - - - - - - - - 名师精心整理 - - - - - - - 第 3 页，共 3 页 - - - - - - - - -