4. Nursing care of complications
Gastrointestinal bleeding is carried out according to the nursing routine of gastrointestinal bleeding.
(4) Rehabilitation guidance
1. Instructions for medication: Take medicine regularly according to the doctor's advice, and prohibit or use drugs that stimulate gastric mucosa such as aspirin and indomethacin with caution. Take antacids, gastric mucosal protective agents and other drugs correctly.
2. Information and activities
Live a regular life, strengthen exercise, keep warm, and avoid tension and fatigue.
3. Dietary guidance Daily diet should pay attention to timing and regularity, do not overeat, and pay attention to food hygiene.
4. Follow-up guidance for regular review of gastroscopy and Hp examination.
Two. Nursing quality standard
(1) can take the medicine correctly according to the doctor's advice and master the function and side effects of the medicine.
(2) Master the correct eating habits.
Section VI, Nursing care of gastroesophageal reflux disease.
(esophagitis. Barrett's esophagus)
1. nursing points
(1) disease observation
(1) Observe whether the patient has heartburn, chest pain, dysphagia and other symptoms.
(2) Observe whether there are symptoms of nausea, vomiting and salivation.
(3) Observe the degree of dysphagia and eating.
(2) the implementation of treatment
1, special inspection
During electronic gastroscopy and X-ray examination, patients should be told to fast and drink water for 4-8 hours.
2, according to the doctor's advice to give infusion treatment.
(3) Nursing measures
1, symptomatic care
When sleeping, raise the bedside 15-30cm to reduce reflux. Don't lie flat immediately after eating, but stand upright 1 hour.
2, diet care
Limit high-fat, chocolate, strong tea, coffee and other foods that reduce LES stress, eat less and eat more meals, and avoid full meals and midnight snacks. Control your weight, because obesity will lead to an increase in abdominal pressure and cause reflux.
3. Psychological care
Patiently explain the treatment process of the disease and eliminate the tension and fear of patients.
(4) Rehabilitation guidance
1, activity guidance
Pay attention to rest, avoid overload, increase abdominal pressure, and don't wear corsets.
2, medication guidance
Take medicine according to the doctor's advice on time, and avoid taking drugs that reduce the pressure of lower esophageal sphincter, such as nitroglycerin, atropine, 654-2, etc.
3. Follow-up guidance
If you feel unwell, you should go to the hospital in time.
Two. Nursing quality standard
(1) Patients received dietary guidance from nurses.
(2) Understand the pathogenesis and treatment process of the disease.
Section 7, Nursing care of liver cirrhosis.
First, the nursing points
(1) Disease observation.
(1) To observe the manifestations of decompensated cirrhosis: decreased liver function (emaciation, fatigue, dull complexion, low fever, nausea, abdominal distension, aversion to oil, anemia, nose, gums, gastrointestinal bleeding, liver palm, spider nevus, etc. ), portal hypertension (splenomegaly, ascites, esophageal and gastric varices, abdominal varices, etc. ).
(2) Observe whether there are mental and neurological symptoms and signs of hepatic coma (such as consciousness, expression, personality change and flapping-wing tremor, etc.). ).
(3) Observe whether there are any complications. Such as upper gastrointestinal bleeding, hepatic encephalopathy, infection, hepatorenal syndrome, hepatopulmonary syndrome, primary liver cancer and electrolyte acid-base balance disorder.
(2) the implementation of treatment
According to the routine nursing of digestive system diseases.
(3) Nursing measures
1. Medication nursing was given diuretics according to the doctor's advice, and the urine volume of patients after medication was observed and recorded.
2. Dietary health care diet follows the principle of "one low, two high and three noes", that is, foods with low fat (avoid fatty animal viscera), high protein and high vitamins, do not drink alcohol, and do not eat hard foods (such as beans, celery, peels, etc.). ), and don't eat raw food (eating raw meat or raw fish can lead to parasitic infection).
3. Symptom nursing
(1) Nutritional disorders should be given a diet with high calorie, high quality protein, low fat, low salt and high vitamins, avoiding eating hard food, and giving nutritional support through intravenous infusion.
(2) Abdominal distension and edema
Limit the intake of water and salt, accurately record the intake and output, measure the abdominal circumference and weight regularly, and assist doctors in nursing abdominal puncture.
(3) constipation is given laxatives according to the doctor's advice to keep the stool unobstructed.
(4) Ascites ① Take a semi-recumbent position when there is a large amount of ascites. ② Diet care: low-salt or salt-free diet is given according to the illness, and the daily liquid intake is not more than 1 000 mL. ③ Skin care: keep the bed dry and flat, and often apply hot compress and massage to the pressed parts. ④ Observe the regression of ascites, pay attention to whether there is dyspnea and palpitation, accurately record the daily inflow and outflow, and measure the abdominal circumference and weight regularly.
(5) When the urine volume is less than 400 mL/d or there is no critical value of urine or electrolyte, notify the doctor in time.
4. Special treatment and nursing: Do abdominal puncture, release ascites, urinate before operation, observe whether there is dyspnea during and after operation, prevent leakage at the puncture site, and change the dressing when necessary. Samples are sent for inspection in time.
5. Psychological nursing is a long process of liver cirrhosis, so it is necessary to give patients spiritual comfort and support, keep a happy mood and rest at ease.
6. Skin care jaundice can cause skin itching, so you should avoid scratching the skin, turn over regularly and clean the skin.
7. Safety protection For patients with restlessness, protective measures such as restraint belts and bed bars should be applied to avoid falling off the bed.
8. Nursing care of complications
(1) esophageal variceal bleeding
According to the routine nursing of upper gastrointestinal bleeding.
(2) Infection
Give anti-inflammatory drugs according to the doctor's advice, and give physical cooling when fever occurs.
(3) Hepatic encephalopathy
Regular monitoring of vital signs and consciousness, if there is consciousness disorder, according to coma care.
(4) Rehabilitation guidance
(1) medication instructions
Guide to take medicine on time and in quantity, and avoid using drugs harmful to the liver.
(2) Dietary guidance
Diet follows the principle of "one low, two high and three don't", and drinking and smoking are prohibited. Avoid inducing factors of esophageal varices rupture, such as eating coarse food, drugs, severe cough, increased abdominal pressure, etc.
(3) rest activities
Exercise properly, avoid excessive fatigue and ensure adequate sleep. In the decompensated period, it is necessary to stay in bed and reduce the burden on the liver, which is conducive to the recovery of liver cells.
(4) Follow-up guidance
Regular examination of liver function and liver color ultrasound is not suitable for follow-up.
Second, the nursing quality standards
(1) Observe the condition in time, and correctly record the quantity, weight, abdominal circumference, etc.
(2) Find the precursor of hepatic coma in time and handle it in time.
(3) Patients should master general disease knowledge and self-care methods.
Section 8 Nursing of Acute Pancreatitis
First, the nursing points
(1) disease observation
(1) Closely observe the changes of patients' temperature, pulse, respiration, blood pressure and consciousness.
(2) Observe the location, nature, degree and radiation site of abdominal pain.
(3) Observe whether there are digestive tract symptoms such as nausea, vomiting, abdominal distension, exhaust and defecation.
(2) the implementation of treatment
1. Special inspection
Collect blood samples correctly and check blood amylase urgently.
2. Special preparation
Gastrointestinal decompression according to the doctor's advice.
(3) Nursing measures
1. Drug care
According to the doctor's advice, atropine and adriamycin were used to relieve spasm and pain. Is it forbidden? Pump somatostatin at a uniform speed according to the doctor's advice to ensure the unobstructed infusion pipeline, use the injection pump correctly and ensure the accurate medication.
2. Dietary care and fasting are one of the main treatments for acute pancreatitis, which can reduce pancreatic secretion and help inflammation subside. During fasting, patients are thirsty and can gargle or wet their lips with water. After the symptoms improve, light liquid and semi-liquid soft food will be given gradually, and high-fat diet is still prohibited during the recovery period.
3. Symptom nursing
(1) Pain
(1) Pay attention to safety in case of severe pain, use safety instructions to prevent falling off the bed, and ask family members to accompany them 24 hours a day and use the bed rail. ② Give analgesic and antispasmodic drugs according to the doctor's advice. (3) Fasting according to the doctor's advice, giving gastrointestinal decompression, recording the 24-hour inflow and outflow, keeping the pipeline unobstructed, properly fixing the pipeline, and preventing the pipeline from stretching and slipping.
(2) Nausea and vomiting
① Take lateral or supine position, with the head tilted to one side. (2) After vomiting, assist the patient to gargle and clean up the vomit in time. (3) Change the contaminated clothes and bedding in time. (4) Open the window for ventilation to reduce the smell of vomit. ⑤ Give antispasmodic and antiemetic treatment according to the doctor's advice.
4. Psychological care
Explain the importance of fasting to patients, eliminate their bad psychological activities, and guide patients to relax their muscles by using relaxation techniques (such as slow' deep breathing').
5. Oral care
Oral care should be done routinely during gastrointestinal decompression. Correct fixation to maintain smooth drainage.
(4) Rehabilitation guidance
1. Dietary guidance should focus on low-fat foods, such as bean products, protein, fish, lean meat, rice, noodles, steamed bread, fresh vegetables and fruits. Quit smoking and drinking, and avoid overeating.
2. Rest activities
Develop good living habits, ensure sleep and avoid fatigue.
3. Follow-up guidance
Half a month after discharge, the outpatient department rechecked the upper abdomen CT and went to the hospital immediately in case of emergency.
Second, the nursing quality standards
(1) Observe the condition in time and standardize the nursing records accurately.
(2) Pump somatostatin at a constant speed in strict accordance with the prescribed dose.
(3) Gastrointestinal decompression is effective, unobstructed and properly fixed.
Section 9 Nursing care of primary liver cancer
First, the nursing points
(1) disease observation
(1) Observe whether there are abdominal pain, abdominal distension and diarrhea, as well as the nature, location, degree and duration of pain in the liver area, and observe whether there are symptoms such as nausea, vomiting and forced posture.
(2) Observe vital signs and state of consciousness to see if there are symptoms of irritability or drowsiness.
(3) Observe whether there is bleeding caused by portal hypertension, such as melena and hematemesis.
(4) Observe the food intake and nutritional status.
(2) the implementation of treatment
According to the routine nursing of digestive system diseases.
(3) Nursing measures
1. Dietary care is given a high-calorie and high-vitamin diet. In order to ensure the intake of protein, people with hepatic coma should abstain from eating protein, and should be given a low-protein diet of 30 g/d after waking up. People without hepatic encephalopathy can eat normally.
2. Symptom care
(1) Pain
Give appropriate painkillers according to the doctor's advice, provide a quiet environment and comfortable posture, and take physical cooling or drug cooling when fever occurs.
(2) coma
According to the coma routine nursing.
(3) Bleeding
Dynamic observation of blood pressure changes, stool color and properties, observation of fecal occult blood and hemoglobin changes.
(4) ascites
① A large number of patients with ascites take semi-recumbent position to relieve dyspnea. ② The daily liquid intake should not exceed 1000 mL, and a low-salt diet (2-3g/ day) should be given. (3) When using diuretics, record the inflow and outflow for 24 hours according to the doctor's advice, and measure the abdominal circumference and weight regularly.
3. Psychological care
Encourage patients to establish confidence in overcoming diseases and keep patients happy. Give spiritual comfort to family members, explain the possibility of illness change, and strengthen contact with family members.
4. Skin care for terminally ill patients, avoid pressure ulcers, encourage patients to move in bed or assist patients to change their positions, turn over regularly, and use air cushion beds when necessary. Start safety notification, inform patients and their families about related matters, and ask their families to accompany them 24 hours a day to avoid adverse events.
(4) Rehabilitation guidance
1. Instructions for medication
Take medicine according to doctor's advice.
2. Dietary guidance
Strengthen nutrition, eat less and more meals, and eat more light and soft foods with low fat, high calorie and rich vitamins.
Rest activities
Pay attention to rest, avoid fatigue, and avoid unfavorable factors such as catching cold and catching a cold.
Second, the nursing quality standards
(1) Observe the patient's condition in time, and the nursing records are true and complete.
(2) the correct implementation of the doctor's advice, the implementation of treatment.
(3) Nursing measures were put in place, and no nursing complications occurred.
Section 10, Nursing care of inflammatory bowel disease (ulcerative colitis, Crohn's disease)
First, the nursing points
(1) disease observation
(1) Observe the nature, frequency and quantity of diarrhea and the degree of gross hematuria.
(2) Observe the location, degree, temperature change and weight loss of abdominal pain.
(3) In acute stage, due to frequent defecation, we should observe whether there are symptoms such as thirst, weakened skin elasticity, emaciation, fatigue, palpitation, decreased blood pressure, imbalance of water and electrolyte, acid-base balance and nutritional disorder.
(2) the implementation of treatment
1. Special inspection
When doing electronic colonoscopy, prepare the intestine.
2. Special drugs
Use hormones and immunosuppressants in strict accordance with the doctor's advice.
(3) Nursing measures
1. Symptom nursing
(1) Observe vital signs, find out whether there are complications such as intestinal obstruction and toxic Hirschsprung's disease in time, and inform the doctor in time if the condition changes.
(2) Diarrhea ① Accurately record the frequency and nature of stool, estimate the amount of bleeding when the amount of bloody stool is large, keep the test specimens in time, and notify the doctor to give hemostatic drugs according to the doctor's advice. In severe cases, observe the changes of vital signs and accurately record the amount of entry and exit. ② Nutritional support guides patients to eat a diet with less irritation, less cellulose and high calorie. Fasting first when bleeding heavily, switching to liquid diet and residue-free diet according to the condition, and using milk and dairy products with caution. ③ People with frequent diarrhea should do a good job in cleaning and nursing the perianal skin. Warm water cleans the perianal skin. If you need to protect the skin, you can apply MEBO.
2. Special treatment and care
Drug retention enema should be carried out before going to bed at night. First, let the patient clear feces and perform low-pressure retention enema.
3. Psychological care
Give psychological support to promote early recovery.
(4) Rehabilitation guidance
1. Dietary guidance: give a diet with sufficient calories, protein, rich vitamins and less residue, and eat more in small quantities to avoid food that irritates the intestines.
2. Rest activities
Those who are light should be encouraged to engage in general light work, and those who are heavy should stay in bed to ensure sleep.
3. Follow-up guidance
If you feel unwell, review and follow up regularly.
Second, the nursing quality standards
(1) The patient did not change or add or subtract drugs at will.
(2) Keep the samples correctly and send them for inspection in time.
(3) Patients should master the purpose and significance of enema and insist on treatment.
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