Edema nursing routine
First, nursing evaluation
(a) whether there is edema, edema characteristics and its severity.
Judging the degree of edema:
1) is mild, only found in eyelid, suborbital soft tissue, subcutaneous tissue of tibia and ankle, and slightly depressed tissue can be seen after finger pressing, and it quickly flattens.
2) Moderate and obvious edema can be seen all over the body, obvious or deep depression can be seen after finger pressing, and it is calm and slow.
3) The whole body tissue is severely edema, the lower skin is tense and shiny, and even there is fluid oozing. In addition, pleural effusion, abdominal cavity and tunica vaginalis can be seen, and severe edema can also be seen in vulva.
(B) the physical and mental effects of edema
Check for skin ulcers or secondary infections; Whether there are symptoms and signs of respiratory and circulatory system related to the increase of volume load, especially those of acute pulmonary edema.
(three) diagnosis, treatment and nursing process
Medical consultation after edema, focusing on whether to use diuretics, as well as the types, dosage, usage, efficacy and adverse reactions of drugs; Whether there are restrictions on diet and drinking water and their implementation.
Second, the nursing measures:
(1) rest
Those with mild edema must limit their activities, and strenuous activities are strictly prohibited.
Those with severe edema and those with heart, liver and renal insufficiency with edema should stay in bed and increase the blood flow of liver and kidney, which is beneficial to the edema regression.
(2) Lying position
The pillow of patients with eyelid and facial edema should be slightly higher; People with edema of both lower limbs should lie flat as far as possible, and raise their lower limbs 30 ~ 45 at rest. It is beneficial to blood circulation and reduces edema. Patients with hydrothorax and ascites should take a sitting position or a semi-sitting position to improve the dyspnea caused by pulmonary dilatation limitation and diaphragm elevation. Proper bed exercise to prevent venous thrombosis of limbs. Patients with scrotal edema use scrotal belt to hold up scrotum to help edema subside.
Patients with acute nephritis and nephrotic syndrome should stay in bed until the edema subsides. For chronic nephritis, the activity of patients can be determined according to the severity of edema, normal blood pressure and urine routine. During the remission and recovery period, outdoor activities, such as walking and playing Tai Ji Chuan, can promote blood circulation and facilitate early recovery.
(3) Sodium and water intake
In principle, the diet with less salt is 2-3 g per day, and no salty food is added. The amount of water you drink every day depends on the cause, degree and urine volume of edema.
Cardiogenic edema: the daily salt intake is less than 5g, and the daily water intake is less than 1500ml.
Hepatic edema: limited water intake per day 1000ml, hyponatremia 500 ml per day.
Renal edema: daily urine output 1000ml is generally not limited, but it is not advisable to drink more water. If the daily urine output is less than 500ml, limit the amount of liquid, and in severe cases, live within your means (the previous day's urine output +500ml).
(4) Skin care
1) Protect the skin from harm. Clothes should be soft and loose, and bed units should be clean and dry without wrinkles. Avoid dragging, pulling and dragging when turning over, so as not to damage the edema area by friction. Complicated with scrotal edema, be sure to stay in bed and hold up the scrotum with a cotton pad or towel. The size of the fold should be based on the size of scrotal edema, and the height should be comfortable without falling.
2) Prevention of skin infection: Those who use diuretics for frequent urination should pay attention to the cleanliness of perineum.
3) Intravenous puncture infusion therapy Nursing Before venipuncture, press the swollen tissue with your fingers to expose the blood vessels and push away the subcutaneous moisture, which can easily enter the needle. Observe the local skin closely during infusion. The skin of edema patients is thin and easy to be damaged. When uncovering the adhesive tape after infusion, the adhesive tape can be soaked in sterile physiological saline and slowly removed. When pulling out the needle, the time to press the eye of the needle should be extended until the liquid does not leak out.
(5) Drug care
1) Reasonable arrangement of medication time: diuretics should not be taken at night to avoid affecting sleep.
2) Observe the curative effect of drugs: monitor the inflow and outflow for 24 hours to see whether the edema subsides.
3) Observation of adverse drug reactions: The concentration of serum electrolyte was measured as needed during medication.
Hypokalemia is characterized by fatigue, nausea, vomiting, abdominal distension, weakening or disappearance of intestinal peristalsis, early heart rate acceleration and arrhythmia. Electrocardiogram showed that T wave was flat and inverted, and U wave appeared.
Hyponatremia is mainly manifested as muscle weakness, muscle spasm, dry mouth, dizziness, gastrointestinal dysfunction and so on.
Hypoxic alkalosis is mainly characterized by excitability and neuromuscular overexcitation, and in severe cases, tonic spasm may occur.
(6) Health education
1) inform the patient of the causes of edema and the relationship between edema and sodium water retention;
2) Reasonably arrange the salt content and water consumption of food every day;
3) Instruct patients to avoid salty food, canned food, beer, soda, monosodium glutamate, bread, dried bean curd and other foods rich in sodium, and instruct patients to use sodium-free salt, vinegar, lemon and so on to stimulate their appetite.
4) Measure the daily liquid intake correctly, and measure the weight after urinating before meals in the morning. If you have severe systemic water, excessive weight gain or increased dyspnea at night and after fatigue, it may be early heart failure and you should seek medical attention in time;
5) Introduce the names, usage, dosage, effects and adverse reactions of related drugs to patients in detail, and inform patients not to add, subtract or stop drugs without authorization.
reference data
Swim Dawn and Wu Ying. Medical nursing. Beijing: People's Health Publishing House, 4th Edition, April 2008.
Editor-in-chief Dai Baozhen. Practical symptom nursing. Shanghai: Fudan University Press, 2nd Edition, April 2005.
& lt& lt Clinical Nursing Practice Guide; & gt Beijing People's Military Medical Publishing House, version 1, July 201/.
Modified: 20 13-4- 16.