The nursing diagnosis is: (1) the temperature rises, which is related to pulmonary infection. (2) Impaired gas exchange is related to ventilation and ventilation disorder caused by lung inflammation and pulmonary circulation congestion caused by heart failure. (3) Low respiratory tract cleaning efficiency: It is related to increased respiratory tract respiration and secretion and poor expectoration function. (4) Potential complications: The side effects of drugs are related to the application of digitalis and furosemide in heart failure.
2 nursing measures
In view of the above nursing diagnosis, we have taken the following nursing measures.
2. 1 Nursing of high fever Close observation of the changes of children's body temperature, such as high and low body temperature and violent fluctuations, indicates that the condition is serious. If the temperature exceeds 38.5℃, physical cooling or antipyretic drugs should be given according to the doctor's advice, and the efficacy should be observed and recorded. Dry the sweat and change clothes in time after sweating, strengthen oral care, eat lightly, eat less and eat more meals, and give a liquid or semi-liquid diet with high protein, high calorie and high vitamins.
2.2 Nursing care of damaged gas exchange
2.2. 1 Keep quiet and pay attention to prone position, because children with hypoxia are often restless, which further increases the body's oxygen consumption and cardiopulmonary burden. Therefore, attention should be paid to keeping the environment in the ward quiet, avoiding crying and excessive activities, reducing unnecessary stimulation to facilitate rest, bedding should be light and soft, clothing should avoid causing discomfort or excessive sweating of children, underwear should not be too tight, so as not to affect breathing, staff should speak softly, walk lightly, operate lightly, care and treatment should be concentrated as much as possible, intravenous infusion should be used as far as possible, and sedatives should be used reasonably according to the doctor's advice. Generally, the head position is high or half-lying, so it is necessary to turn over frequently to change the body position, so as to reduce the amount of blood returning to the heart and relieve pulmonary congestion, thereby improving dyspnea and reducing the heart load.
2.2.2 oxygen supply oxygen flow and oxygen supply time are determined according to the degree of hypoxia. In early childhood, lung elastic tissue is underdeveloped, alveoli are small and few, blood vessels are abundant, the gap between capillaries and lymphatic tissue is wider than that of adults, and interstitial development is vigorous, so the whole lung tissue contains more blood and less gas. Respiratory muscle dysplasia, ribs close to the horizontal position, small breathing capacity, limiting the expansion. Because of the anatomical characteristics of the above development, children often have insufficient gas exchange, insufficient gas storage and low respiratory efficiency. Children usually compensate by speeding up their breathing frequency. The symptoms of dyspnea are more obvious when the lung tissue is inflamed. Therefore, it is very important to take oxygen in time. Always check whether the pipeline is unobstructed when inhaling oxygen, so as to avoid blockage and affect the curative effect. Observe the changes of cyanosis around the mouth and limbs, nasal agitation, auxiliary respiratory muscle movement and three concave signs. Do blood gas analysis when necessary and guide the use of oxygen.
2.2.3 Administration According to the doctor's advice, anti-infective drugs, digitalis preparations and diuretics were given to eliminate lung inflammation, correct heart failure, promote gas exchange and observe the efficacy of drugs.
2.2.4 Treatment of abdominal distension Handle abdominal distension in time to avoid affecting breathing. Traditional Chinese medicine or turpentine can be used to hot compress the abdomen and drain the anal canal. If hypokalemia is caused, potassium should be supplemented according to the doctor's advice; If it is caused by toxic intestinal paralysis, fasting and gastrointestinal decompression should be done, and neostigmine should be given according to the doctor's advice to promote intestinal peristalsis, eliminate abdominal distension and relieve dyspnea.
2.3 Care for cleaning respiratory tract (1) Maintain proper indoor temperature and humidity, encourage children to drink plenty of water, and prevent phlegm from being sticky and difficult to cough up. (2) Help the child turn over and tap the back to facilitate secretion discharge or postural drainage. (3) Ultrasonic atomizing inhalation dilutes sputum to promote cough; Suck sputum when necessary to keep the respiratory tract unobstructed.
2.4 Care of digitalis and diuretics (1) The pulse should be measured before each application of digitalis, and the heart rate should be heard if necessary. Infant pulse rate ≤ 100 beats/min, and child pulse rate ≤80 beats/min, and should be reported to the doctor in time to decide whether to stop taking the medicine. (2) Pay attention to execute the doctor's advice on time and in quantity, and don't mix it with other drugs to ensure the accuracy of digitalis dosage. (3) Ceylon injection time should not be less than 65438±05min. (4) Diuretics should be administered in the morning or in the morning, so as to avoid frequent urination at night affecting sleep and hypokalemia, so as not to increase the toxic reaction of digitalis.
2.5 Other nursing care of children with other pneumonia complicated with heart failure should strictly limit the speed of fluid replacement and infusion, record the inflow and outflow in detail, pay attention to the observation of vital signs, the pulse must count to 1 min, and pay attention to the changes of children's mental state and behavior.