Question 2: I am a nursing student. What are the main nursing diagnoses of edema? What are the excessive retention of body fluids in interstitial or body cavities called edema? But edema usually refers to the increase of interstitial body fluids, and the increase of body fluids in body cavities is called edema. Edema can be manifested as local or systemic. When systemic edema occurs, serous effusion, such as ascites, pleural effusion and pericardial effusion, often occurs at the same time.
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, there may be effusion in the thoracic cavity, abdominal cavity and tunica vaginalis cavity, and severe edema can also be seen outside.
(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: People who regularly use diuretics to urinate will pay attention to cleanliness.
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
......& gt& gt
Question 3: What are the common nursing problems? What are the nutritional disorders? This is related to being below the needs of the body.
Anxiety: It is related to worrying about the prognosis of the disease.
Lack of knowledge: lack of relevant knowledge
These three can mention anything.
Impaired gas exchange: related to bronchospasm, airway obstruction or airway injury.
Impaired skin integrity: related to long-term bed rest.
Potential complications: foot drop, chasing pneumonia, urinary tract infection.
These all depend on the condition and the patient's personal situation.
Internal surgery and nursing.
What are the main nursing diagnoses of problematic DIC? Answer: There are three main points in the nursing diagnosis of DIC: (1) the skin integrity is damaged; Bleeding; Related to DIC; (2) There is a risk of bleeding; Skin mucous membrane or visceral bleeding; Related to DIC; (3) Changes of tissue perfusion; Hypotension or shock; It's about DIC
Question 5: What are the nursing diagnoses of the North American Association of Nursing Diagnostics? 1. exchange.
Malnutrition: more than the body needs.
Malnutrition: below the body's needs.
Malnutrition: Potential exceeding physical needs.
There is a risk of infection.
Risk of temperature change.
Hypothermia (hypothermia)
Hyperthermia; hyperthermia
Invalid temperature adjustment is invalid.
Reflex disorder
constipation
Perceptual structure
colon sex constipation
Diarrhea (diarrhea)
Intestinal incontinence
Urination change
Stress urinary incontinence (Sires urinary incontinence)
Reflex out of control
Urgency urinary incontinence
Functional incontinence (functional incontinence)
Total incontinence (total incontinence)
Urine retention
Altered tissue perfusion (kidney, brain, heart and lungs, gastrointestinal tract, peripheral blood vessels).
Excess liquid
Insufficient liquid capacity
Risk of insufficient liquid capacity.
Decreased cardiac output (deer. A. Ed Caderas Cooper)
Damaged gas exchange (infrared gas exchange)
Invalid airway cleaning.
Invalid breathing pattern
You can't maintain spontaneous breathing, you can't maintain it.
Ventilator dependence (DVWR)
Risk of injury.
Danger of suffocation.
Trauma risk.
Risk of inhalation.
Self-protection ability changes (change protection)
Impaired organizational integrity.
Oral mucosal changes
Impaired skin integrity
There is a risk of damage to skin integrity (risk of damage ...>& gt
Question 6: What are the nursing diagnoses of shock patients? 1. Nursing diagnosis and nursing problems
1, body fluid deficiency is related to blood loss, fluid loss and abnormal distribution of body fluid.
2. The change of tissue perfusion is related to the decrease of effective circulating blood volume.
3. Impaired gas exchange is related to insufficient perfusion of lung tissue and pulmonary edema.
4. The risk of injury is related to the disturbance of consciousness caused by hypoxia of brain cells.
5. The risk of infection is related to invasive monitoring, indwelling catheter, decreased immune function, tissue damage and malnutrition.
6. Potential complications of multiple organ system failure (MSOF).
Second, the nursing of expanding blood volume
1. Establish two venous channels to ensure rapid and effective blood volume replenishment.
2, closely observe the changes of vital signs and central venous pressure, and pay attention to the presence of acute pulmonary edema, acute heart failure, so as to adjust the amount and speed of fluid replacement at any time.
3. Observe urine volume and urine specific gravity to judge whether there is acute renal failure, whether fluid replacement is sufficient, and whether shock has improved.
4. Put the head, chest and lower limbs in supine position respectively, and raise 10-30 to increase blood volume and cardiac output, which is beneficial to breathing.
5, carefully record the amount of in and out, to provide reference for further treatment.
Third, improve the nursing of tissue perfusion
To improve tissue perfusion, in addition to rapidly expanding blood volume, appropriate use of vasoactive drugs is also one of the important measures. The nursing of expanding blood volume is as mentioned above, and the nursing of applying vasoactive drugs is mainly summarized here.
1, vasoconstrictor, because it can aggravate tissue hypoxia and bring adverse consequences, it is not recommended to use it alone; Vasodilators can relieve vasospasm, close A-V short circuit, dredge microcirculation, increase tissue perfusion and cardiac blood volume, but they can only be used when blood volume is replenished.
2. According to the condition, especially in the early stage of shock, vasoconstrictors and vasodilators can be combined.
3, the use of vasoactive drugs should start from a small dose, low concentration, slow speed, and closely observe the changes of the disease, according to the need to adjust the dosage, concentration and speed.
4, intravenous drip vasoconstrictor, should be careful to prevent drug overflow outside the blood vessels and lead to tissue necrosis.
Fourth, other care.
1, promote gas exchange ① Give atomized inhalation, turn over and pat the back to promote expectoration, and perform tracheotomy when necessary to keep the respiratory tract unobstructed. ② Routine intermittent oxygen supply, 6-8L/ min, to improve blood oxygen concentration. ③ Encourage deep breathing and effective cough, promote lung expansion and increase alveolar gas exchange. ④ If necessary, use artificial respiration machine and give positive end-expiratory pressure to assist breathing, so as to improve the anoxic state.
2, dealing with abnormal body temperature For hypothermia, take warm measures, such as raising the room temperature and covering the quilt, but don't use hot water bottles, electric blankets and other body surface heating to prevent skin capillaries from expanding, further reducing visceral blood flow and aggravating shock. During blood transfusion, the blood should be rewarming before blood transfusion to avoid aggravating hypothermia. For those with high body temperature, cooling measures should be taken to keep the body temperature below 38℃.
3, to prevent injury and infection (1) fidgety, should be properly protected to prevent falling from the bed. (2) skin care, frequent replacement of * * * to prevent bedsores; Do a good job in oral care to prevent oral mucosal infection and ulcer. (3) All kinds of medical supplies shall be strictly disinfected, and all medical operations shall comply with aseptic operation procedures. ④ Give antibiotics correctly and on time according to the doctor's advice to prevent double infection. ⑤ Follow the doctor's advice. Give nutritional support therapy to improve the body's resistance.
4. Psychological nursing Take corresponding nursing measures according to the psychological status of patients and relatives.
What are the main nursing diagnoses of problematic DIC? Answer: There are three main types of nursing diagnosis of DIC: (1) skin integrity damage; Bleeding; Related to DIC; (2) There is a risk of bleeding; Skin mucous membrane or visceral bleeding; Related to DIC; (3) Changes of tissue perfusion; Hypotension or shock; It's about DIC