Ineffective respiratory pattern
[Associated factors]
1. Respiratory muscle weakness.
2. Neuromuscular involvement.
3. Hypoxia.
[Main manifestations]
Shallow and slow breathing.
Cyanosis of the lips, skin and mucous membranes, nasal flutter.
Cough and sputum.
Marked respiratory triple concave sign.
Blood gas analysis of oxygen partial pressure above normal or accompanied by higher than normal carbon dioxide partial pressure.
[Goals of care]
The patient is able to maintain good respiratory status without dyspnea and cyanosis and has normal arterial blood gas analysis values.
The patient is able to maintain an optimal respiratory pattern with reduced dyspnea.
[Nursing measures]
Elevate the head of the bed to facilitate breathing.
Keep the oxygen line open.
Encourage the patient to cough, breathe y, and aspirate if necessary.
Accompany the patient during acute episodes of dyspnea to provide a sense of security in order to reduce anxiety and fear and facilitate breathing.
Wear loose, soft clothing so as not to interfere with breathing.
Observe the patient's respiratory rate, rhythm and depth, if you find respiratory effort, slow respiratory pouring, coughing, swallowing difficulties should be prepared for tracheal intubation, mechanical ventilation equipment, ready to cooperate with the resuscitation.
If necessary, cooperate with the doctor to perform tracheotomy.
After tracheotomy, the skin around the incision should be strictly sterilized, and the wound gauze should be changed in time to prevent infection.
Disinfect the endotracheal tube 4 times a day.
Cooperate with the physician to check the blood analysis regularly and observe whether the hypoxic condition is improved.
The rounds should be intensified and assistance given when necessary.
[Focused evaluation]
Whether the patient's hypoxia and dyspnea have been improved; whether the degree of bruising of the skin, mucous membranes, and lips has been reduced or disappeared; and whether the nasal flanks are agitated, and whether the three-concave sign has disappeared.
Monitor arterial blood gas analysis values; whether the patient can maintain good respiratory status.
Whether the patient can take effective measures to cough and cough up sputum.
Ineffective suction tract
[Associated factors]
1. Increased secretions due to lung infection.
2. Weakness or fatigue of the cough.
3. Impaired consciousness and cognitive impairment.
[Main manifestations]
Thickness of breath sounds, shallow and rapid breathing with nasal flutter and triple concave sign.
High respiratory secretions, cough and sputum.
Weakness of cough and inability to cough up sputum effectively.
Assisted ventilator due to respiratory distress.
Low partial pressure of oxygen and elevated partial pressure of carbon dioxide on arterial blood gas analysis.
[Nursing goals] Maintain the patient's airway patency as evidenced by clear breath sounds, normal respiration and effective coughing up of sputum after treatment and deep breathing.
Keep the indoor air fresh, ventilate the room twice a day for 15-30 minutes each time, and pay attention to keep warm.
Maintain the room temperature at 18 ∽ 22 ℃, 50% ∽ 70% (dry air can be sprinkled in the room).
If the patient has sputum sounds, encourage the patient to cough, instruct the patient on effective sputum evacuation methods, and give negative pressure suction of sputum if necessary.
Guide the patient to carry out postural drainage, and assist the patient to turn over and pat the back before expectoration, patting the back from top to bottom and from outside to inside.
Use antibiotics as prescribed by the doctor and observe the efficacy and side effects of the drugs.
Giving nebulized inhalation and oxygen as prescribed by the doctor to achieve the purpose of diluting sputum and anti-inflammatory.
Encourage drinking as much water as the heart can tolerate.
[Focused evaluation]
Is the airway open.
Ability to cough up sputum effectively.
Is the respiratory status improved, with or without dyspnea and use of an assisted ventilator.
Three, impaired limb movement
[Associated factors]
Paralysis of the limbs.
Neuromuscular involvement.
Disorders of consciousness.
[Major manifestations]
Paralysis of the limbs, loss of motor function of the limbs.
The patient's ability to take care of himself or herself is reduced, and he or she is unable to carry out activities of daily living, such as walking, dressing, eating, washing and combing the hair.
[Nursing goals]
The patient's needs are met while in bed.
The patient is able to perform activities with assistance, such as helping to walk and dress.
The patient achieves an optimal level of self-care, e.g., eating by himself, combing his hair, etc.
[Nursing care measures]
Assess the patient's ability to move the affected limb and develop a nursing care plan with the patient***.
Place the affected limb in a functional position to prevent sequelae such as foot drop and claw hand.
Guide the patient to actively exercise the affected limb, and give encouragement to the achievements made.
Timely assistance and supervision of the patient to carry out functional exercise, according to the condition of the passive movement in bed → active activities in bed → bedside activities → out of bed activities in order to achieve the intensity of moderate, gradual and persistent. The amplitude of passive movement from small to large, from large joints to small joints; massage should be carried out with gentle and slow techniques.
Teach the patient's family members and their companions how to perform the exercises.
The patient should be accompanied by a chaperone to prevent injuries.
Combined with acupuncture, physical therapy, etc., to promote the recovery of limb function.
Encourage patients to carry out self-care activities to adapt to the needs of returning to the family and society.
[Focused evaluation]
Whether the patient's ability to perform activities of daily living is improved.
Whether the patient is safe during activities and whether there are any injuries.
IV. Impairment of the integrity of the skin: the possibility of bedsores
[Related factors]
Paralysis of the limbs.
Prolonged bed rest.
Inadequate nutrition.
[Main manifestations]
Dry skin, poor elasticity, easily broken.
Localized skin pressure for a long time, skin redness, reactive congestion.
Heavy sweating and moist skin.
Malnutrition, poor skin elasticity, and little subcutaneous fat at the bony prominence.
[Goals of care]
No bedsores.
The patient feels clean and comfortable.
[Nursing measures]
Turn the patient over once every 2 hours, massage the local bone protrusion pressure, and pay attention to turn over to avoid pushing, pulling, dragging action, so as not to rub the skin.
Sleeping on an air mattress, the bone protrusion pad soft pillow or rubber ring, in order to reduce the local pressure.
Keep the bedsheets clean, dry, flat and free of debris. When you sweat a lot, scrub in time and change clean clothes and pants.
Attention to reasonable eating, strengthen nutrition, enhance resistance.
Daily hot water foot soak, warm water bath, promote blood circulation in the body.
[Focused evaluation]
Whether bedsores occur.
Whether the patient feels clean and comfortable.
V. Perceptual changes
[Associated factors]
Demyelinating lesions of peripheral nerves.
Damage to sensory conduction pathways.
[Goals of care]
The patient is free from injury.
Promote return of perception to normal.
[Nursing Measures]
Scrub the sensory-impaired body part with warm water every day to promote blood circulation and sensory recovery.
Keep the bed neat, dry, and free of crumbs to prevent damage to the sensory impaired body parts.
Pay attention to keep the patient's limbs warm, but when using hot water bag, the water temperature should not be more than 50 ℃ to prevent burns.
Give limb massage and passive movement.
Assist in turning over, once every 2 hours, and do diligent massage, diligent replacement, diligent organization, diligent scrubbing, to prevent the occurrence of decubitus ulcers.
Frequently give the patient to do perceptual training, such as paper, wool, etc. to stimulate shallow touch, warm water to stimulate temperature sensation, stimulate pain sensation with acupuncture and so on.
[Focused evaluation]
Whether the factors that led to the patient's injury have been ruled out.
Whether the patient's perception gradually returns.
VI. Self-care deficits
[Relevant factors]
Paralysis of limbs.
Impaired consciousness.
Strength and weakness.
[Major manifestations]
Inability to perform activities of daily living, such as eating, dressing, grooming, bathing, toileting, and getting out of bed.
Increased dependency.
Perceptual impairment.
[Goals of care]
The patient feels clean and comfortable while in bed, and his or her life needs are met.
The patient is able to perform self-care activities, such as combing the hair, washing the face, going to the toilet, and dressing.
The patient basically returns to the original level of self-care in daily life.
[Nursing measures]
Encourage the patient to perform self-care activities.
Put the items frequently used by the patient in an easily accessible place for easy access at any time.
Signal lamps are placed at the patient's hand and answered immediately when the bell rings.
Assist the patient in dressing, grooming, hygiene, bathing, toileting, and feeding during bedtime.
The patient is instructed to wear loose, soft clothes and shoes that do not need to be laced.
Patients need to be accompanied when going out to prevent accidental injuries.
[Focused Evaluation]
Whether the patient's living needs are met and whether the bed unit is clean and comfortable.
Whether the patient can fully regain the ability to take care of himself in daily life and what self-care activities he can perform.
VII. Fear
[Related factors]
Difficulty in breathing, sense of near death.
Sudden decrease in motor strength.
Altered health.
Fear of tracheotomy.
[Major manifestations]
Self-reported panic, fright, and restlessness.
There was crying and refusal behavior.
Sensitivity and paranoia.
Rapid heartbeat, shortness of breath, flushed or pale skin, excessive sweating, agitation, insomnia, and dreams.
[Goals of Care]
The patient has less fear and fewer fearful behaviors and signs.
The patient is able to describe the psychological feelings of fear.
The patient is able to adopt positive coping methods in response to fear.
[Nursing measures]
Expressing understanding of the patient's fear, encouraging the patient to express his feelings, and patiently listening to the patient's reasons for his fear.
Patiently explain to the patient the course of the disease, treatment and prognosis, and encourage the patient to establish confidence in overcoming the disease.
Patiently instructing the patient to improve breathing to reduce the patient's sense of impending death.
Before cooperating with the physician to perform tracheotomy, give the patient a good explanation to eliminate the patient's panic and fear of psychology.
The patient is instructed to use relaxation techniques, such as: slow deep breathing, whole body muscle relaxation, listening to soft music.
Try to avoid the patient's contact with rescue or critical patients.
Family members participate in **** with efforts to ease the patient's fear, such as companionship, distracting conversation, appropriate massage, etc..
The patient's progress in time to give positive encouragement.