Section 1 Key points of respiratory system related knowledge
A, anatomy, physiology, pathology:
Respiratory tract: nasal cavity, pharynx, larynx, trachea and bronchus; (ventilated, clean, warm and humid air)
Lung: (the main part of gas exchange)
Function of respiratory system: inhale oxygen and expel carbon dioxide, so as to ensure normal metabolism and relative stability of internal environment.
Second, the common symptoms nursing points:
(1) Cough and expectoration
1. Nursing evaluation: (1) Understand the medical history; (2) Observe the characteristics of cough and expectoration: the nature, timbre and rhythm of cough, the color, quality, quantity and smell of sputum, and whether it is easy to cough up; (3) Understand the accompanying symptoms and signs: the relationship with body position, whether there is fever, chest pain, dyspnea, rales, etc. (4) Understand the treatment and related examination: What expectorant and antitussive drugs have been used; (5) Understand the patient's psychological state;
Please think: What is the relationship between the color and smell of phlegm and diseases? )
2. Nursing diagnosis: (1) respiratory tract cleaning is ineffective: it is related to ineffective cough, phlegm, fatigue, chest pain and disturbance of consciousness; (2) There is a risk of suffocation: it is related to disturbance of consciousness, inability to expel phlegm, and increased respiratory secretions blocking the respiratory tract;
Please think: how to care for patients with cough and expectoration?
3. Nursing measures★: (1) Humidify the airway; (2) Turn over and buckle your back; (3) Instruct effective cough and expectoration; (4) Postural drainage; (5) mechanical sputum aspiration;
Please think about it: what methods can be taken to dilute sputum for patients with sticky phlegm who are not easy to cough up? Why do you want to turn over and buckle your back?
(2) Hemoptysis
1. Nursing evaluation: (1) Understand the medical history; (2) Understand the blood volume, color and characteristics★: A small amount of hemoptysis: 500ml/d or 300ml/ time; (3) Observe the patient's vital signs and find asphyxia in time; (4) Understand the treatment and related examinations; (5) Understand the patient's psychological state;
Thinking: How to find the symptoms of suffocation in time?
2. Nursing diagnosis: (1) Asphyxia risk: related to consciousness disorder and airway obstruction caused by massive hemoptysis;
(2) Infection risk: related to blood retention in bronchus;
3. Nursing measures★: (1) Rest and posture: a small amount of hemoptysis: rest in repose; Massive hemoptysis: Absolute bed rest. Assist the patient to lie flat and tilt his head to one side; (2) Avoid forced defecation and stabilize patients' mood. (3) Keep clean and comfortable: rinse the mouth for the patient in time and wipe the blood; (4) Observation of illness: Observe the characteristics of vital signs, consciousness, pupils and hemoptysis, and pay attention to whether there are signs of suffocation; Precursors of suffocation: chest tightness, suffocation, cyanosis of lip nails, pale face, cold sweat, irritability, etc. (5) Prevention of asphyxia: Tell the patient not to hold his breath when hemoptysis occurs, keep the respiratory tract unobstructed, and prepare rescue drugs and articles (first aid articles such as sputum suction tube and tracheal intubation). (6) Asphyxiation rescue nursing★:1) Clear the hemoptysis in the respiratory tract in time: ▲ Take the head with low feet and high prone position immediately; ▲ Pat the back to promote the patient to cough up blood; ▲ Rapid sputum aspiration by nasal catheter, or sputum aspiration by tracheal intubation or bronchoscopy; 2) High flow oxygen inhalation; 3) establish venous access and take medicine according to the doctor's advice (hemostasis, sedation and cough); 4) Stabilize patients' mood; 【 Note: When pituitrin is used for massive hemoptysis, the dropping speed should be controlled; Hypertension, coronary heart disease, heart failure and pregnant women are prohibited] 5) Closely observe the condition and be alert to suffocation again: observe the patient's vital signs, the amount, color, nature and bleeding speed of hemoptysis. 6) Blood matching and transfusion when necessary;
(3) Pulmonary dyspnea (please think about the types and causes of pulmonary dyspnea)
1. nursing evaluation: (1) medical history; (2) Characteristics of dyspnea: changes in attack, type, breathing frequency, depth and rhythm. Assess the degree of dyspnea and hypoxia and understand the accompanying symptoms; (3) Treatment and related examination: use of antibiotics and expectorants, chest X-ray, sputum examination and arterial blood gas analysis;
(5) The patient's mental state and sleep;
2. Nursing diagnosis: (1) Impaired gas exchange: related to the decrease of breathing area caused by lung diseases and airway stenosis or emphysema caused by bronchial smooth muscle spasm; (2) Inefficient breathing pattern: It is related to airway stenosis caused by bronchial smooth muscle spasm;
3. Nursing measures: (1) Rest and environment: Take proper posture, such as semi-lying position or sitting position, and set a small table opposite the bed when necessary to facilitate the patient to rest;
(2) Assist the patient in expectoration: keep the respiratory tract unobstructed;
(3) according to the doctor's advice correct oxygen therapy★:
▲ General hypoxia without carbon dioxide retention: oxygen can be given at a general flow rate (2 ~ 4L/min) and concentration (29% ~ 37%).
▲ Severe hypoxia without carbon dioxide retention: oxygen can be given by mask for a short time, with intermittent high flow (4 ~ 6L/min) and high concentration (45% ~ 53%). ▲ Hypoxia with carbon dioxide retention (pao 2 < 60 mmhg, PaCO 2 > 50 mmhg): oxygen can be continuously given through nasal catheter or nasal plug at low flow rate (1 ~ 2l/min) and low concentration (25% ~ 29%);
(4) Observe the curative effect of oxygen therapy in time: adjust the oxygen concentration and flow rate in time; (5) Pay attention to humidified oxygen: replace the disinfection oxygen inhalation device regularly to prevent cross infection;
(4) Chest pain
1. Nursing evaluation: (1) Understand the medical history; (2) Understand the location, nature, degree and duration of chest pain; (3) Observe the accompanying symptoms and signs: whether it is accompanied by fever, cough, hemoptysis, dyspnea, cyanosis, shock and other discomfort. (4) Understand the treatment and related examinations, such as the use of analgesics, chest radiographs and sputum. (5) Understand the patient's psychological state;
2. Nursing diagnosis: (1) Pain is related to chest wall diseases and visceral diseases; (2) Anxiety is related to worrying about the prognosis of the disease;
3. Nursing measures: (1) Rest and posture: adopt correct posture to ensure patients have a good rest; (2) Stabilize patients' mood; (3) to guide the methods of relieving pain;
Please think about what you have learned: how to guide patients to relieve pain?
Summary: 1. The common symptoms of respiratory system are cough, expectoration, dyspnea, hemoptysis and chest pain.
2. The main nursing measures for respiratory symptoms are as follows: (1) promoting expectoration nursing and keeping respiratory tract unobstructed;
(2) asphyxia rescue nursing;
(3) Correct implementation of oxygen therapy, etc.
The second quarter acute respiratory tract infection (acute upper respiratory tract infection, acute tracheobronchitis)
Thinking: 1. Have you ever caught a cold in your life? How did you do? How long is the course?
2. What are the causes of colds?
Acute upper respiratory tract infection:
Evaluation of patients: 1. Etiology and pathogenesis: 1. Virus (mostly caused by virus) 2. Bacteria: the body's resistance and respiratory defense function decline-> the original bacteria in the upper respiratory tract or viruses and bacteria invaded by the outside world multiply;
Second, clinical manifestations: 1. Common cold; 2. Acute viral pharyngitis: pharyngeal discomfort; 3. Acute laryngitis: hoarseness and pain; 4. Bacterial pharyngitis and tonsillitis: acute onset, sore throat, chills, fever (high fever);
Three, inspection and diagnosis:
(1) Examination: 1. Hemogram: when the virus is infected, the white blood cell count is normal or low, and the classified lymphocytes are elevated; During bacterial infection: white blood cell count and neutrophil count increased; 2. Detection of viruses and virus antibodies, and bacterial culture;
(2) Diagnosis: 1. Have a history of cold or contact with patients with upper respiratory tract infection; 2. Symptoms such as stuffy nose, runny nose, sore throat, general fatigue, fever, general aches and headaches; 3. Physical examination only showed congestion and edema of upper respiratory mucosa;
Make a plan:
Fourth, the treatment point: 1. Symptomatic treatment: antipyretic, analgesic, expectorant, etc. ; 2. Etiological treatment: antiviral and antibacterial; 3. Chinese herbal medicine treatment;
Verb (abbreviation of verb) Nursing diagnosis/problem: 1. High fever: related to virus and/or bacterial infection;
Implement nursing care
Six, nursing measures★:1. Rest and diet: stay in bed during fever, have a light and digestible diet and drink plenty of water.
2. Symptomatic nursing: (1) high fever nursing; (2) keep the respiratory tract unobstructed;
3. Disinfection and isolation to prevent cross infection;
4. Observe the condition and be alert to complications;
(Accompanied by earache, tinnitus, hearing loss, and purulent external auditory canal-beware of otitis media;
If the patient has fever, aggravated headache, purulent nose and sinus tenderness-beware of sinusitis;
If there are symptoms such as edema, palpitation and joint pain in the recovery period-beware of myocarditis, nephritis or rheumatoid arthritis; )
5. medication care: take medicine according to the doctor's advice and pay attention to the curative effect.
6. Health guidance: prevent cold and keep warm, enhance physical resistance, and make timely diagnosis and treatment;
Effect evaluation: To evaluate the patients' physical and mental reactions to diseases, treatment and nursing after nursing.
Acute bronchitis
Evaluate patients
I. Etiology and pathogenesis
(1) Etiology: 1. Virus or bacterial infection; 2. Physical and chemical factors or allergic reactions;
(2) pathogenesis: etiological stimulation->; Congestion, edema and infection of trachea and bronchial mucosa;
Second, clinical manifestations: 1. Symptoms of acute upper respiratory tract infection; 2. Cough and expectoration; 3. Signs: the breathing sounds of both lungs are thick, and the lungs are scattered with dry and wet rales;
Three, inspection and diagnosis:
(1) Examination: 1. Blood routine: the results are similar to acute upper respiratory tract infection;
2. Sputum smear or culture: pathogenic bacteria can be found;
3.x-ray chest film: mostly normal or thickened lung texture;
(2) Diagnosis: ▲ History of upper respiratory tract infection; ▲ Cough, expectoration, dry and wet rales in both lungs; ▲ Blood picture and chest X-ray examination for reference;
draw up a plan
Iv. treatment score: 1. Etiological treatment: antiviral and antibacterial; 2. Symptomatic treatment: relieving cough, eliminating phlegm, etc.
Implement nursing care
V. Nursing diagnosis/problems and measures:
(1) Nursing diagnosis/problems: 1. Impaired gas exchange: related to bronchospasm;
2. High fever: related to tracheobronchial infection;
(2) Nursing measures: basically the same as upper respiratory tract infection.
Effect evaluation
After the implementation of nursing, the patients' physical and mental reactions to diseases, treatment and nursing were evaluated.
Class summary: 1. Acute upper respiratory tract infection is mainly the symptom of itchy throat;
2. Acute bronchitis is mainly cough and expectoration.
3. When the virus causes it, the hemogram is not high; When caused by bacteria, white blood cells increase;
4. Treatment and nursing mainly focus on the causes and symptoms.
Section 3 ★ Chronic Obstructive Pulmonary Disease
Chronic bronchitis obstructive emphysema
summary
1.COPD:( 1) Lung diseases with limited airflow;
(2) The air flow restriction is not completely reversible, but presents progressive development;
(3) It is closely related to chronic bronchitis and emphysema;
2. Chronic bronchitis: chronic nonspecific inflammation of trachea, bronchial mucosa and its surrounding tissues;
3. Obstructive emphysema: the air cavity at the distal end of the terminal bronchioles in the lung expands abnormally and continuously, accompanied by the destruction of bronchioles in the alveolar wall;
The relationship between 4.4. Chronic obstructive pulmonary disease and chronic bronchitis and obstructive emphysema?
When the lung function examination of patients with chronic bronchitis and/or emphysema shows that the airflow is limited and not completely reversible, it can be regarded as COPD.
Chronic bronchitis ★ (abbreviation: chronic bronchitis)
Evaluate patients
Case introduction: The patient is a 65-year-old man who has been coughing and expectoration for more than 20 years, which is obvious in autumn and winter every year and lasts for 3 ~ 4 months. Recently 1 week, cough became worse, accompanied by fever. Check: T38℃, P 1 16 times/min, R32 times/min, P 130/75mmHg, wet rales were audible in both lungs. The initial diagnosis is: chronic bronchitis (acute attack)
Please consider this patient in combination with the above cases:
1. Why is it diagnosed as chronic bronchitis? 2. What is the main cause of this disease? 3. How to treat and care?
I. Etiology and pathogenesis
(1) Etiology: 1. Smoking-the most important factor leading to chronic bronchitis; 2. Respiratory tract infection; 3. Physical and chemical factors; 4. Climatic factors (cold); 5. Others: allergic reaction, nutritional status, etc.
(2) pathogenesis: various causes->; The airway mucosa is damaged, ciliary movement is inhibited, phagocytosis of macrophages is reduced, and mucus secretion is increased->; Mucosa and cartilage atrophy, bronchioles and alveolar wall structure destruction;
Second, the clinical manifestations
(1) Symptoms: chronic cough, expectoration or wheezing.
(2) logo: 1. There may be no abnormal signs in the early stage; 2. When accompanied by infection, wet rales can be heard in both lungs;
(3) Classification: simple type (cough, phlegm); Wheezing type (cough, phlegm, wheezing)
Simple type: mainly manifested as cough and expectoration.
Wheezing type: besides coughing and expectoration, there is still wheezing, accompanied by wheezing, which is aggravated when coughing and obvious when sleeping;
Clinical staging:
Acute attack period: pus and phlegm appear within one week, and the amount of phlegm is obviously increased, or accompanied by inflammatory manifestations such as fever, or cough, excessive phlegm and asthma are obviously aggravated.
Chronic protracted period: those who have cough, expectoration and asthma of different degrees for more than one month.
Clinical remission period: the symptoms basically disappear or occasionally have a slight cough and a small amount of phlegm, which lasts for more than two months.
Three, inspection and diagnosis:
Auxiliary inspection: 1. Blood routine; 2.WBC、n^； 3.e wheezing; 4.x-ray examination; There is no abnormality in the early stage, and the lung texture increases and thickens with the progress of the disease, especially in the middle and lower fields of both lungs. 5. Respiratory function examination; 6. Sputum examination: A large number of neutrophils can be seen on smear, and pathogenic bacteria can be detected by culture;
(2) Diagnosis: Cough and expectoration for more than 3 months every year; For two consecutive years or more; Eliminate chronic cough caused by other known causes;
draw up a plan
Fourth, the main points of treatment
Teach yourself and discuss what drugs are commonly used in acute attacks.
(1) Acute attack period: 1. Control infection; 2. Cough and expectoration; 3. relieve spasm and asthma;
(II) Chronic delay period (same as above)
(3) Clinical remission period: 1. Enhance physical fitness; 2. Avoid all kinds of pathogenic factors; 3. Strengthen nutrition;
Verb (abbreviation of verb) Nursing diagnosis/problem: 1. Ineffective or inefficient respiratory tract cleaning: related to ineffective cough and phlegm;
2. High fever: related to chronic bronchitis complicated with infection;
Implement nursing care
Six, nursing measures★
1. Rest and activity: (1) Absolute bed rest during acute attack; (2) Patients with dyspnea should take a semi-recumbent position; (3) Pay attention to adequate sleep;
(4) Combination of rest and work in remission period, avoiding strenuous exercise and sudden exertion, and preventing complications.
2. Diet: (1) People who can eat should be given a diet rich in protein, vitamins, calories, digestible and potassium;
(2) Drink plenty of water, quit smoking and drinking, and keep defecation;
(3) limiting the intake of water and sodium in patients with edema;
3. Symptomatic nursing: cough and expectoration nursing: (1) Deep breathing and effective cough: helpful for the discharge of distal airway secretions;
(2) Humidification atomization therapy: drink plenty of water and use saline, gentamicin sulfate, α -chymotrypsin and other drugs for atomization inhalation according to the doctor's advice every day;
(3) chest percussion and chest wall vibration; (4) Postural drainage; (5) mechanical sputum aspiration;
4. Rational use of antibiotics according to doctor's advice: Thinking on nursing of common antibiotics combined with pharmacology.
Choose antibiotics according to the drug sensitivity test of pathogenic bacteria;
For example, erythromycin and roxithromycin are effective against gram-positive cocci and mycoplasma;
Amoxicillin, cefuroxime and cefaclor are effective against both gram-negative and gram-positive bacteria.
Ofloxacin has a stronger effect on gram-negative bacteria and is suitable for those who are allergic to penicillin and cephalosporins.
▲ Penicillin: Ask about allergic history, use it now and take the medicine on time;
▲ Cephalosporin: There are some cross-allergic reactions with penicillins;
▲ Macrolides: It should be taken after meals;
▲ aminoglycosides: pay attention to ear and kidney toxicity;
5. Disease observation: (1) Observe the onset time and inducing factors of cough, phlegm and asthma, especially the nature and quantity of phlegm. Evaluate clinical classification and staging, such as simple or wheezing, acute attack or chronic delay. (2) Observe whether there is dyspnea, severe cough and expectoration, chills, fever and palpitations.
6. Health guidance: (1) 1. Quit smoking; (2) To educate patients and their families about this disease; (3) Keep warm to prevent colds; (4) reasonable diet; (5) combine work and rest to enhance physical fitness;
case analysis
1. Diagnostic analysis: The patient has a history of repeated chronic cough and expectoration, which meets the diagnostic criteria of chronic bronchitis. Because there is no evidence of wheezing, it belongs to simple type. There was a serious infection recently 1 week, which was in the acute attack stage.
2. Nursing analysis: (1) The cough and expectoration lasted for more than 10 years, and the symptoms worsened 1 week-keep the respiratory tract unobstructed and observe the expectoration; (2) Coughing yellow pus and phlegm-cooperating with the application of antibiotics; (3) fever-fever care; (4) Weakness-diet, rest and nursing; (5) Lack of health guidance knowledge about the disease;
Class summary: 1. Chronic bronchitis is nonspecific inflammation of bronchi, and smoking, cold and respiratory infection are the most important reasons.
2. The main symptoms are cough, excessive phlegm and asthma. Cough, phlegm and wheezing last for three months every year for two years or more. If other diseases are ruled out, a diagnosis can be made.
3. The treatment and nursing of acute attack should pay attention to keeping respiratory tract unobstructed and anti-infection.
Obstructive emphysema ★ (abbreviation: emphysema)
Evaluate patients
Case introduction: A 69-year-old male patient, who smoked for 40 years and repeatedly coughed and expectorated for 30 years, had attacks for more than 3 months every year. Dyspnea for 5 years. Physical examination: temperature 38.6℃, pulse 102 beats/min, respiration 26 beats/min, blood pressure 130/70mmHg. Conscious, cyanotic lips, chest, decreased respiratory movement, decreased speech tremor, voiceless after percussion, and wheezing in both lungs. Blood routine: WBC 12.2× 109/l X-ray: the transparency of both lungs increased. The initial diagnosis was chronic bronchitis and obstructive emphysema.
Combined with the above cases, please think: 1. Why were chronic bronchitis and obstructive emphysema initially diagnosed?
2. What is the relationship between chronic bronchitis, obstructive emphysema and chronic obstructive pulmonary disease?
3. How to treat and care?
Chronic obstructive pulmonary disease: (1) COPD: chronic obstructive pulmonary disease; (2) A group of diseases with irreversible lesions of airway obstruction and obstructive ventilation dysfunction; (3) including chronic bronchitis, emphysema, some asthma with emphysema and other diseases; (4) The order of cause of death: 4th in the world; (5) Incidence rate: with the increase of age, male >; Female, north > south, winter > summer;
First, the etiology and pathogenesis:
(1) Etiology Smoking is the most important factor: (1) External factors: physical and chemical factors, smoking, infection, climate, allergic factors and occupational factors;
(2) Internal cause: the local defense function and immune function of respiratory tract decreased;
Autonomic nerve dysfunction: increased parasympathetic nerve reactivity;
(2) Pathogenesis: Chronic bronchitis develops continuously->; Bronchial wall destruction, lumen stenosis, alveolar wall destruction, air inlet is larger than air outlet. -& gt； Emphysema;
Physical fitness assessment: (1) Primary symptoms: cough, excessive phlegm and asthma; (2) Manifestations of emphysema: dyspnea is getting worse;
(3) Hypoxia: cyanosis, headache, lethargy and delirium;
Second, the clinical manifestations★
(1) Symptoms: chronic cough, expectoration+dyspnea aggravated;
(2) logo: 1. Visual diagnosis: the anterior and posterior diameter of thoracic cavity increased (barrel chest) and respiratory movement weakened;
2. Palpation: the tremor is weakened or disappeared;
3. Percussion: voiceless, the boundary of voiced heart sounds becomes narrow or difficult to knock out, and the lower limit of lung sounds and the boundary of liver sounds move down.
4. Auscultation: Breathing sounds are generally weakened, exhalation is prolonged, and heart sounds are far away.
(3) Staging: 1. Acute exacerbation period; 2. stable period;
(4) Complications: pulmonary heart disease, spontaneous pneumothorax, respiratory failure, etc.
(5) Clinical classification: emphysema type, bronchitis type and mixed type;
Three, inspection and diagnosis:
(1) Examination: 1. X-ray examination: the transparency of both lung fields increased, and the anterior and posterior diameter of thoracic cavity increased;
2. Lung function examination: RV/TLC & gt；; 40%, FEV 1/FVC < 70%, which is the main objective index to judge the airflow blockage;
3. Arterial blood gas analysis: The partial pressure of arterial oxygen decreased and the partial pressure of carbon dioxide increased in COPD patients.
(2) Diagnosis: history of chronic bronchitis; Aggravate dyspnea; Signs of emphysema; Abnormal respiratory function and X-ray changes.
draw up a plan
Four. Treatment points ★
Chronic obstructive pulmonary disease: 1. Acute exacerbation: (1) controlled oxygen therapy: continuous low-flow oxygen inhalation ★; (2) control infection; (3) Application of bronchodilators; (4) Application of glucocorticoid; (5) Others: promoting expectoration and supplementing water and electrolyte.
2. Treatment in stable period: (1) Avoid induction; (2) relieving cough and eliminating phlegm: using bronchodilator; (3) Long-term home oxygen therapy (LTOT )★
(See Nursing for specific methods)
Indications of long-term home oxygen therapy: (1)PaO2≤55mmHg or SaO2≤80%, with or without hypercapnia;
(2) pao 255 ~ 70 mmhg or SaO2≤89%, accompanied by pulmonary hypertension, right heart failure or polycythemia;
(4) Rehabilitation ★: respiratory function exercise; Muscle training; Nutritional support; Psychotherapy, etc.
(5) Immunomodulation therapy: such as Hezhi injection, thymosin injection, BCG injection, etc.
Verb (abbreviation of verb) nursing diagnosis/problem
1. Impaired gas exchange: It is related to ventilation and ventilation dysfunction caused by airway obstruction, decreased lung tissue elasticity and increased residual volume;
2. Cleaning the respiratory tract is ineffective or inefficient: related to respiratory inflammation, obstruction, excessive phlegm, thick phlegm and inability to cough;
Implement nursing care
Six, nursing measures★
1. Early stage: (same as chronic bronchitis and stable COPD nursing)
2. Acute aggravation 2. COPD: (1) Rest and posture: auxiliary semi-recumbent position, sitting position or raising the bedside appropriately;
(2) keep the respiratory tract unobstructed; (how to raise it? )
(3) Oxygen therapy nursing: continuous low-flow oxygen inhalation. (Why? )
(4) Medication care: Observe the efficacy and adverse reactions of drugs, and prohibit the abuse of cough medicine, sleeping pills and sedatives;
(5) Observation of illness: ▲ Vital signs (especially observation of breathing) ▲ Cough and expectoration ▲ Symptoms and signs of hypoxia and carbon dioxide retention ▲ Arterial blood gas analysis, etc.
3. The stable period is 3. COPD: (1) Rest and posture: Rest reasonably, and adopt semi-recumbent position, upper body forward position and upright position as appropriate, with support points on the back when standing;
(2) Diet: high in protein, calories and vitamins, easy to digest, avoiding too much sugar and gas-producing food;
(3) Long-term home oxygen therapy nursing: remind patients and their families to pay attention to oxygen safety and strictly control the oxygen flow according to the doctor's advice. The oxygen flow rate is 1 ~ 2L per minute, and the oxygen inhalation time is >; 15h/d；
(4) Respiratory function exercise ★: Lip-contraction abdominal breathing, breathing exercise and whole body exercise;
(5) Psychological nursing;
(6) Health guidance: avoiding inducement (quitting smoking), rehabilitation exercise and home oxygen therapy;
Effect evaluation: To evaluate the patients' physical and mental reactions to diseases, treatment and nursing after the implementation of nursing.
Case study:
1. Diagnostic analysis: The patient has a history of smoking, chronic bronchitis, barrel chest and signs of emphysema. X-ray chest film shows that the transparency of both lungs is increased, which is consistent with the diagnosis of chronic bronchitis and obstructive emphysema. Moreover, due to the recent fever, cough, purulent sputum and leukocytosis, the patient was initially diagnosed as acute attack of chronic bronchitis and obstructive emphysema.
2, nursing analysis: (1) yellow pus and phlegm are not easy to cough up, fever, leukocytosis-keep the respiratory tract unobstructed, observe the sputum discharge, cooperate with the application of antibiotics, expectorants, fever care;
(2) dyspnea-continuous low-flow oxygen inhalation;
(3) using bronchodilators and glucocorticoid-drug care;
(4) malnutrition: less than the body's needs-diet care;
(5) Smoking-instructing to quit smoking and avoid catching a cold.
Class summary: 1. The typical symptom of emphysema is dyspnea that gradually increases on the basis of cough, phlegm and asthma.
2.COPD has a bucket chest, weak respiratory movement, weakened speech tremor, voiceless after percussion, and weakened breathing sound.
3. Causes of aggravation: smoking, cold and respiratory infection.
4. The focus of treatment and nursing is continuous low-flow oxygen inhalation and respiratory function exercise in stable period.
The fourth quarter chronic pulmonary heart disease ★ (referred to as: chronic pulmonary heart disease)
Evaluate patients
Case introduction: The patient, male, 67 years old, smoked for more than 40 years, had a history of chronic bronchitis for more than 20 years and was short of breath for 5 years. Examination: T36℃, P96 beats/min, R20 beats/min, BP 130/85mmHg, bucket chest, voiceless, tactile tremor and alveolar breathing sound weakened after bilateral lung percussion. The apical beat is located outside the left fifth intercostal clavicle midline 1.0cm. Auxiliary examination: white blood cells11.0×109/l x-ray: the transparency of both lungs is increased and the pulmonary artery is dilated. The initial diagnosis was chronic pulmonary heart disease.
Please consider the above case: 1. Why is it diagnosed as chronic pulmonary heart disease? 2. What is the relationship between chronic pulmonary heart disease and chronic obstructive pulmonary disease? 3. How to treat and care?
Conclusion: Chronic pulmonary heart disease is a kind of heart disease with or without right heart failure, which is caused by chronic lesions of lung tissue, pulmonary vessels or chest cavity, resulting in increased pulmonary vascular resistance and pulmonary artery pressure.
First, the etiology and pathogenesis:
(1) Etiology: 1. Chronic Bronchial and Pulmonary Diseases: The Most Common Cause of Chronic Obstructive Pulmonary Diseases in China;
2. Severe thoracic deformity; 3. Pulmonary vascular diseases. 4. Others: neuromuscular diseases, sleep apnea syndrome, etc.
(2) Pathogenesis: 1. Formation of pulmonary hypertension: (1) Functional factors: hypoxia, hypercapnia, acid reflux;
(2) Anatomical factors: exacerbation of chronic bronchitis, destruction of alveolar wall, destruction of capillary network and remodeling of pulmonary vascular anatomy;
Pathogenesis: (as shown above)
Second, the clinical manifestations★
(1) compensatory period of pulmonary and cardiac function: 1. Manifestations of primary disease; 2. Pulmonary hypertension and right ventricular hypertrophy;
(2) Decompensation of pulmonary heart function: 1. Respiratory failure: (1) Common inducement: acute respiratory infection;
(2) Manifestations: dyspnea is aggravated, and severe cases have pulmonary encephalopathy such as lethargy and blindness;
Please think: What is pulmonary encephalopathy? Pulmonary encephalopathy, also known as carbon dioxide anesthesia, appears with the aggravation of carbon dioxide retention during respiratory failure. Manifestations are: apathy, muscle tremor or flapping-wing tremor, convulsion, lethargy, coma, etc.
2. Right heart failure: (1) Symptoms: aggravation of primary symptoms, palpitation and digestive system symptoms;
(2) Signs: cyanosis, jugular vein dilatation, increased heart rate, murmur, hepatomegaly, tenderness, positive hepatojugular vein reflux sign and edema;
3. Complications: water, electrolyte, acid-base balance disorder, pulmonary encephalopathy, arrhythmia, shock, gastrointestinal bleeding, DIC, etc.
Pulmonary encephalopathy is the main cause of death from chronic pulmonary heart disease. )
Three, inspection and diagnosis:
(1) Examination: 1. X-ray examination: signs of pulmonary hypertension and right ventricular hypertrophy;
2. Blood examination: red blood cells and hemoglobin can increase, and the total number of white blood cells increases during acute infection;
3. Blood gas analysis: hypoxemia and/or hypercapnia;
4. ECG examination: right ventricular hypertrophy, pulmonary P wave;
(2) Diagnosis: history of chronic bronchitis, emphysema or other chest and lung diseases; Pulmonary hypertension, right ventricular enlargement and/or right heart failure; X-ray, EKG and ultrasound showed signs of right ventricular hypertrophy and enlargement;
draw up a plan
Four, treatment points★:
(1) compensatory period of pulmonary and cardiac function: the same as stable period of emphysema.
(2) decompensated period of lung and heart function: (principle: lung-oriented, heart-assisted ★)
1. Treatment of respiratory failure: refer to Section 5 of this chapter;
2. Control heart failure: (1) Control infection and improve breathing; (2) The principle of using diuretics: slow, small and intermittent; (3) cardiotonic application: pay attention to the application indications and be alert to digitalis poisoning; (4) vasodilators;
Verb (abbreviation for verb) Nursing diagnosis/problem:
1. Impaired gas exchange is related to hypoxemia, carbon dioxide retention and increased pulmonary vascular resistance;
2. The ineffectiveness of cleaning respiratory tract is related to respiratory tract infection, excessive phlegm and viscosity;
3. Potential complications: pulmonary encephalopathy;
Implement nursing care
Six, nursing measures★
1. rest and activity: (1) compensatory period: same as emphysema care;
(2) Decompensation period: absolute bed rest, attention to life care, attention to take a position conducive to breathing;
(3) improve sleep;
2. Diet: (1) ascites, edema and oliguria: limit the intake of sodium water; (2) A diet with high protein, vitamins and cellulose; (3) eat less and eat more meals;
3. Skin care should pay attention to prevent the occurrence of pressure ulcers.
4. Observation of illness: vital signs, consciousness, urine volume, breathing, etc.
5. Keep the respiratory tract unobstructed: improve ventilation and give oxygen therapy, and continue to give oxygen at low flow and low concentration;
6. Precautions for medication and nursing: (1) Use diuretics: Observe urine volume and electrolyte, and correct water-electrolyte disorder in time according to the doctor's advice;
(2) Use digitalis: correct hypoxia and hypokalemia according to the doctor's advice before use, and pay attention to observe the side effects and toxic side effects;
(3) Using vasodilators: Pay attention to the observation of heart rate and blood pressure;
(4) Use antibiotics: pay attention to whether the infection is under control and whether there is secondary fungal infection;
7. Psychological nursing to comfort and explain, and establish confidence in treatment; 8. Health guidance is basically the same as COPD.
case analysis
1. Diagnostic analysis: The patient has a history of smoking and chronic bronchitis; Shortness of breath for 5 years, bucket chest, unvoiced voice, weakened speech tremor and weakened breathing sound after percussion of both lungs. X-ray: increased transparency, diagnosis of emphysema; Apical pulsation is located outside the clavicle midline 1.0cm, with pulmonary hypertension and large right heart. The initial diagnosis was chronic pulmonary heart disease.
2. Nursing analysis: (1) Shortness of breath-semi-lying position or sitting position, long-term home oxygen therapy and respiratory function exercise;
(2) Activity intolerance-life nursing;
(3) Lack of understanding of this disease-guiding to quit smoking and avoiding cold and other adverse stimuli;
Class summary: ▲ The main cause of chronic pulmonary heart disease: COPD.
▲ Manifestations: decompensated respiratory failure and right heart failure;
▲ Treatment: The principle of treatment is to treat the lung mainly, supplemented by treating the heart;
▲ Nursing focus: control infection, improve ventilation and reasonable oxygen therapy;