发热的护理常规.pdf

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1、1/7下载文档可编辑发热的护理常规（一）评估和观察要点1、评估患者发热的时间、程度及诱因、伴随症状等。2、评估患者的意识状态、生命体征变化。3、了解患者相关检查结果。（二）操作要点1、监测体温变化，观察热型。2、卧床休息，减少机体消耗。3、高热患者给予物理降温或遵医嘱药物降温。4、降温过程中出汗时及时擦干皮肤，随时更换衣物，保持皮肤和床单位清洁、干燥；注意降温后的反应，避免虚脱。5、降温处理 30 分钟后测量体温。6、补充水分放置脱水，鼓励患者进食高热量、高维生素、营养丰富的半流质或软食。7、做好口腔护理。（三）指导要点1、鼓励患者多饮水。2、告知患者穿透气、棉质衣服，寒战时给予保暖。3、告知

2、患者及家属限制探视的重要性。2012-02 修订昏迷的护理常规-第 1 页，共 7 页精品p d f 资料 可编辑资料-2/7下载文档可编辑（一）评估和观察要点1、评估患者昏迷的原因、持续时间、意识状况、瞳孔大小，对光反应等。2、观察患者的生命体征，评估Glascow 昏迷指数及反应程度。3、评估患者的肢体活动情况、肌力、感觉情况。4、评估患者的家庭应对情况及经济状况。（二）操作要点1、保持环境安静及适宜的温湿度，室内光线宜暗，动作轻柔，避免外界刺激2、加用床栏保护，取半卧位（床头抬高30-45 度）或侧卧位。3、保持呼吸道通畅，协助翻身拍背，及时清除口鼻分泌物，去除活动性假牙，舌后坠时给予口

3、咽通气管。4、床边备好吸引器及抢救物品，观察生命体征变化、意识情况、瞳孔大小、对光反应。5、维持水电解质平衡，补充营养，必要时记录出入量。6、保持肢体处于功能位，定时进行功能锻炼，预防肢体畸形，挛缩。7、做好皮肤护理、口腔护理，防止褥疮及口腔粘膜受损。8、保护眼睛，放止角膜受刺激。9、保持大便通畅，每日按摩下腹部促进排便，如有尿潴留，可予留置尿管。（三）指导要点1、告知家属疾病恢复的长久性，鼓励树立战胜疾病的信心。-第 2 页，共 7 页精品p d f 资料 可编辑资料-文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 H

4、U7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2

5、X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 Z

6、F1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4

7、I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档

8、编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM1

9、0K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7

10、N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K13/7下载文档可编辑2、告知家属功能锻炼的重要性及注意事项。3、告知家属唤醒护理的操作方法。2011-01 修订瘫痪的护理（二）评估和观察要点1、评估患者瘫痪发病起始时间、持续时间、频率、诱因及发病的特点。2、评估患者的生命体征，意识状态、心电图、血糖、尿量、精神状况、心理反应等。3、评估患

11、者的肢体活动情况、肌力、感觉情况。（二）操作要点1、协助翻身拍背，鼓励咳痰，保持呼吸道通畅，注意保暖，防止肺部感染。2、床边备好吸引器及抢救物品，观察生命体征变化，必要时记录出入量。3、鼓励患者多饮水，保持外阴清洁，排尿困难者留置尿管。4、多吃水果、蔬菜，少食胀气食物，防止肠胀气及便秘。5、做好皮肤护理，防止褥疮的的发生。6、功能锻炼，预防肢体畸形，挛缩。7、神志不清者加用床栏保护。（三）指导要点-第 3 页，共 7 页精品p d f 资料 可编辑资料-文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R

12、7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L

13、1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K

14、1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:

15、CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K1

16、0T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U

17、7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M

18、2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K14/7下载文档可编辑1、告知患者及家属直线翻身的重要性及注意事项。2、告知患者及家属发生肢体挛缩畸形的可能性及预防措施。3、告知患者穿全棉衣服，注意保暖。2012-02抽搐的护理（一）评估和观察要点1、评估抽搐发生的时间、持续时间、次数、诱因、过程、部位、性质及既往史等。2、评估患者生命体征、意识状态，有无舌

19、咬伤、尿失禁等。3、了解患者头颅影像、电解质、脑电图检查结果等。（二）操作要点1、立即移除可能损伤患者的物品，放入开口器，如有义齿取出，解开衣扣、裤袋。2、取侧卧位，头偏向一侧，打开气道，备好负压吸引器，及时清除口鼻腔分泌物与呕吐物。3、加床栏，必要时约束带保护，吸氧。4、遵医嘱使用镇静药物，观察并记录用药效果。5、抽搐时勿按压肢体，观察患者抽搐发作时的病情及生命体征变化，做好记录。6、避免强光、声音刺激，保持安静。（三）指导要点-第 4 页，共 7 页精品p d f 资料 可编辑资料-文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10

20、T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7

21、 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2

22、K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7

23、 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1

24、T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1

25、文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:C

26、M10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K15/7下载文档可编辑1、告知患者及家属抽搐的相关知识，寻找并避免诱因。2、告知患者及家属抽搐发作时应采取的安全措施。3、告知患者避免危险的活动或职业。4、告知患者单独外出时，随身携带注明病情及家人联系方式的卡片。5、告知患者及家属切勿自行停药或减药。2012-02休克的护理（

27、一）评估和观察要点1、评估患者的气道、呼吸、循环、神志、意识情况、皮肤温度、色泽，毛细血管充盈度、尿量等。2、评估患者生命体征、既往史、过敏史及个人史。3、评估患者的实验室检查结果。（二）操作要点1、安排在单人病室，保持环境安静，避免不必要的搬运。2、建立静脉通道，配合医生进行急救处理。3、保持呼吸道通畅，吸氧。4、注意保暖，根据病情给予适宜体位。5、备齐抢救用品，病情变化及时报告处理。6、遵医嘱使用升压药物或其他药物，观察疗效和副作用。（三）指导要点1、告知患者及家属休克严重性。-第 5 页，共 7 页精品p d f 资料 可编辑资料-文档编码:CM10K10T7N1U7 HU7M2K2X8

28、R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1

29、L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3

30、K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码

31、:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K

32、10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1

33、U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7

34、M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K16/7下载文档可编辑2、告知患者及家属发生休克的危险因素及紧急护理措施。2012-02咯血的护理（一）评估和观察要点1、评估患者咯血的颜色、性状和量，伴随症状，治疗情况，心理反应，既往史及个人史。2、评估患者生命体征、意识状

35、态、面容与表情。3、了解血常规、出凝血时间、结核菌培养等检查结果。（二）操作要点1、大咯血患者绝对卧床，取患侧卧位，出血部位不明白者取仰卧位，头偏向一侧。2、及时清理患者口鼻腔血液，安慰患者。3、吸氧。4、建立静脉通道，及时补充血容量及遵医嘱用止血药物，观察疗效和副作用。5、观察、记录咯血的量、性状。6、床边备好气管插管、吸痰器等抢救用物。7、保持大便通畅，避免用力排便。（三）指导要点1、告知患者及家属咯血发生时的正确卧位及自我紧急护理措施。2、指导患者合理饮食，补充营养，保持大便通畅，大咯血时禁食。-第 6 页，共 7 页精品p d f 资料 可编辑资料-文档编码:CM10K10T7N1U7

36、 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2

37、K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7

38、 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1

39、T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1

40、文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:C

41、M10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10

42、T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K17/7下载文档可编辑3、告知患者及时轻咯出血块，严禁屏气或剧烈咳嗽。4、5、（学习的目的是增长知识，提高能力，相信一分耕耘一分收获，努力就一定可以获得应有的回报）6、-第 7 页，共 7 页精品p d f

43、 资料 可编辑资料-文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4

44、I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档

45、编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM1

46、0K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7

47、N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 H

48、U7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1文档编码:CM10K10T7N1U7 HU7M2K2X8R7 ZF1L1T4I3K1