Respiratory Nursing Rounds _Photo ppt
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Definition of bronchiectasis:-refers to the formation of irreversible expansion of one or more proximal bronchi and medium-sized bronchial wall tissue. It is a common purulent inflammation of the respiratory system. The secondary pathogenic factors are the blockage and traction of bronchial infections, and the department has congenital genetic factors. Patients often have a history of childhood measles pertussis or bronchial pneumonia. Clinically, the typical symptoms are chronic cough with a large amount of purulent sputum and frequent hemoptysis. Chronic cough with a large amount of purulent sputum volume is related to changes in body position, such as increased cough and sputum volume in the morning or dark bedtime, yellow-green pus and sputum are added when acute respiratory infections occur, hundreds of ml a day, if tired An aerobic bacteria infection has an odor. Hemoptysis can occur frequently, ranging from a small amount of sputum to a large amount of hemoptysis, and the severity of the hemoptysis is sometimes not different. Bronchial dilatation and hemoptysis generally have no symptoms of poisoning. Nursing diagnosis If the infection is frequently accompanied by infectious bronchial drainage, sputum is not easy to cough, it can sense chest tightness, discomfort, inflammation and spread to the lung tissue around the lesion, showing symptoms such as high fever, poor appetite, cold sweat, weight loss, and anemia. Chronic Shen's bronchiectasis has severely impaired lung function and obstructs the labor force. When the program is short, shortness of breath and cyanosis accompanied by clubbing fingers (toes). COPD definition:-is a disease that can be prevented and treated with airflow limitation characteristics. Airflow limitation is not completely reversible, and it grows progressively. It takes the lungs to be very inflammable to harmless gases such as snuff smoke or harmless particles. Relevant. COPD secondary affects the lung net, but can also cause (or extrapulmonary) adverse effects. Clinical manifestations of chronic cough: usually the first symptoms. At first, the cough was intermittent and heavier at night. At present, the cough is present sooner or later, but the cough at night is not significant. Few cases have cough without sputum. There are also departmental cases that have relatively limited airflow but no symptoms of cough. (2) Sputum sputum: After coughing, a small amount of mucus sputum is coughed, and department patients are more in the morning; when sputum is merged and infected, sputum volume is increased, and purulent sputum is often present. (3) Shortness of breath or hard breathing: This is a hallmark symptom of COPD. It is a secondary cause of anxiety in the patient. It is presented only during labor and then gradually increases, resulting in shortness of breath during daily programs and even rest. (4) Puffing and chest tightness: not sexual symptoms of COPD. Departmental patients are exceptionally heavy patients with wheezing; tightness usually occurs after labor, and is related to capacitive contraction such as breathing effort and intercostal muscles. (5) Sexual Symptoms: In the clinical course of the disease, patients who are experiencing heaviness and heaviness may develop symptoms such as decreased body sedimentation, decreased appetite, peripheral muscle atrophy and impaired function, depression and / or anxiety. Chronic Pulmonary Cardiomyopathy that can cough up blood, sputum or hemoptysis when merged and infected: Definition:-The most common person with Chronic Pulmonary Cardiomyopathy is Chronic Hypoxic Pulmonary Cardiomyopathy, also known as Obstructive Emphysema Cardiomyopathy Disease, referred to as pulmonary heart disease, refers to a class of cardiopulmonary disease caused by increased pulmonary resistance caused by chronic lesions of the thoracic or pulmonary arteries of the lungs, causing pulmonary hypertension and left ventricular hypertrophy, with or without left heart failure. Pulmonary heart disease is a common disease in our country. The clinical manifestations of chronic pulmonary heart disease in the late stage are persistent cough, sputum, and breathing difficulties of varying degrees. The symptoms are more pronounced after the show or during the cold season. In the later stage of pulmonary heart disease, the cardiopulmonary function is in the tasting stage. The patient has no sexual symptoms, and the patient can be asymptomatic when he is quiet, so the disease is not easy to cause people to notice. However, it is only necessary to present the following environment, which often reminds that already suffering from pulmonary heart disease: ① persistent cough and sputum. ② In the cold season, the condition becomes deeper, the cough worsens, and the sputum volume increases, becomes thicker, or appears. ③ For a few programs such as going up the stairs or walking quickly, you can feel shortness of breath, shortness of breath, palpitations, pain and sadness in the front of the heart, fatigue, chest tightness and other symptoms, which can improve after resting. ④ fingertips, lips and lips are blue-purple. ⑤Accelerated heart rate and arrhythmia. Thanks for the 2011-9-16 Respiratory Nursing Roundup Foundation Materials 26 Beds, Zhang Jinlan, female, 78 years old, retired, married, with 1 son and 2 women. Diagnosis: ① expansion of both lung branches with infection ② obstructive emphysema ③ Decompensated period of chronic pulmonary cardiopathic disease ④ Giant long red blood cell anemia Patients with frequent sputum cough and wheezing for more than 40 years, plus Shen with bilateral lower extremity for more than 2 months, and the current history of the patient was less than two months ago, and the patient presented with asthma Increased Shen, cough, moderate amount of yellow thick sputum, no blood in sputum, asthma is more, asthma is slightly moved, 2011-9-1 08:40 wheelchair pushed into the ward, Shen Qing, wilt, asthma, anemia appearance, Lips and face are pale, lips white, barrel-shaped chest, low breathing sounds in both lungs, wheezing sounds can be heard and scattered, mild concave edema in both lower limbs. T 36.8 ＜ P 84 times / minute R 23 times / minute BP 108 / 59mmHg After admission, follow the doctor's advice and give first-grade care, sickness, general food, 2 liters / minute nasal congestion oxygen, anti-infective, asthma, phlegm, blood transfusion Healed No. 9's stable condition, stopped sickness No. 11's previous history of stopping oxygen inhalation, negates the history of epidemics such as "hepatitis" and "tuberculosis", negates the history of "hypertension" and "diabetes", negates the history of surgery, outside, blood transfusion, negates food and drugs Allergies history, family health history, parents are dead, offspring, healthy. Psychosocial history Family relationship is harmonious, future generations are filial, neighbourhood relationship, patient relationship is excellent. Ke indecent material (No. 1) GT showed increased texture of the two lungs, 恍惚, multiple upper laminar lobes in the left upper lung and left lung, nodular calcifications in the lower left lung, increased lung transparency, increased heart shadow, and pulmonary arteries The thickness was thickened, and the left coronary blood showed strip-shaped high-density calcifications. (No. 2) The heart color Doppler ultrasound showed two, and the tricuspid valve showed a few reflux signals. Left heart function measurement EF 49%, FS25% M ultrasound: Heart rate 104 beats per minute (No. 2) Abdominal color Doppler ultrasound showed that the shape of the gallbladder was normal, the wall was rough, the cavity could detect the strong reflex group, and the scope was about 6 * 4mm. A piece of about 19 * 13 mm non-reverberation area, the rear response strengthens the indecent material (No. 1), blood red and white 36 ↓ (110-160g / L) (No. 1) red blood cells 0.91 ↓ (3.5-5.5 1012 / L) ( No. 1) Platelets 74 ↓ (100-300 109 / L) (No. 1) D-dimer 438.0 ↑ (0-246.4 ug / L) (No. 1) Vitamin B12 70 ↓ (180-917pg / ml) (1 No.) Lactate dehydrogenase 2146 ↑ (90-250u / L) (No. 1) a- 2066.0 ↑ (80-220 u / L) (No. 2) Four syphilis positive (No. 6) morphology of bone marrow cells before blood transfusion The elaboration report announced giant long red blood cell anemia. (No. 7) Lactate dehydrogenase 1017 ↑ u / L (No. 7) a-915 ↑ u / L (No. 12) blood red egg white 111.0 g / L (No. 12) red blood cells 3.40 〜 1012 / L (No. 12) platelets 240 〜 109 / L Nursing diagnosis P1 Clearing the respiratory tract inefficient P2 Impaired gas interchange P3 Programs Intolerance P4 Defective self-care ability P6 Nutrient disorders P5 Excessive fluids P7 Impaired skin integrity P8 Yes P9 Yes Heart failure possible P10 Yes Bleeding may clear the respiratory tract. Inefficient sputum removal and thick and weak coughing. 1 Help the patient to turn over and pat his back. Changing position is good for sputum discharge 2 Pointing patients to drink a little more water, can dilute sputum, easy to discharge 3 Inspire patients to cough, invalid sputum discharge skills 4 Check the color, nature, volume of sputum, collect sputum accurately, and send it on schedule Examination 5 Do aerosol inhalation and dilute sputum as needed. 6 Follow the doctor's advice for antibiotics, antitussive, expectorant use, and check the efficacy and side effects. 7 Inhale sputum when needed. Can hinder related measures 1 Provide patients with tranquility and comfort, the air in the connecting ward is novel, and ventilation is provided on time. 2 Rest in bed, take a semi-recumbent position. 3 Pay attention to oxygen safety and avoid inhalation of oxygen concentration. Use nasal congestion method or mask method. Oxygen concentration 28% ～ 30%, 1.5 ～ 2L / min, time 15h per day. Whether the symptoms of hypoxia improved. Non-invasive ventilation can be used when needed 4 to observe the patient's breathing frequency, rhythm, depth, breathing difficulty and cyanosis 5 monitor arterial blood gas analysis, water electrolyte, pH balance environment program, endurance, hypoxia, hypoxia, anemia related methods 1 cardiopulmonary Decompensation period, absolute bed rest, adequate sleep and rest 2 Provide high-calorie, high-protein, rich vitamins and easy-to-digest foods, 3 limb programs on the bed, exercise limb function 4 Turn over on time to prevent pressure ulcers Excessive bodily fluids, cortical discharge reduction, and edema in both lower limbs 1 The bed unit is clean and dry, and the skin in the edema area 2 is supplied with high-calorie, high-protein, abundant vitamins, easy-to-digest foods, eat less and eat more, and avoid spicy stimuli 3 Check the patient's edema The environment accurately records the revenue and expenditures, and appropriately controls the fluid intake. 4 Infusion care, to regulate the volume and speed of infusions, and to tell patients and their families the main reasons for this practice, in order to prevent them from speeding up the drip rate and tempting anxiety pulmonary edema. . 5 Follow the doctor's advice to use the cardiotonic diuretics. 6 Record the 24 hours of revenue or expenditure or urine output deficiency according to the doctor's order. Take the cardiopulmonary insufficiency, show the endurance-related methods. 1 15-30 minutes visit the ward, understand that patients need to fill their feet in time. Reasonable needs 2 Help patients to wash and urinate, etc. 3 Make the daily necessities easy to access 4 After the condition is unchanged, point the patient to complete the self-care programs within their ability and gradually increase the amount of programs, so that it is better to have skin without feeling asthma Take a long-term stay in bed with impaired integrity and restrict the program. Related measures 1 The bed unit is clean, dry, and slag-free. 2 Inform patients and family members of the factors that cause pressure ulcers and how to prevent them. 3 Turn over once every 1-2 hours and massage. The skin under pressure 4 Pointing the patient into a high-protein, high-calorie, high-vitamin diet 5 Use of air cushion beds and transparent stickers 6 Strictly do skin bedside nutrient imbalance is lower than the body needs to take appetite decline, anemia-related measures 1 Motivate patients , High egg white, high calorie, high vitamin diet, lean meat, liver, kidney, seafood, eggs contain more vitamin B12; novel green leafy vegetables, cereals Liver, kidney and other animals have more net folic acid 2 Vitamin B12 and folic acid are given according to the doctor's advice: Vitamin B12 is given intramuscularly and folic acid is given orally. 3 Those who are not able to receive the medicine are given nasal feeding according to the doctor's advice. Links to oral cleanliness, procrastination, lack of endurance, and lack of vitamin B12 related methods1 Provides patients with tranquility and comfort2 Improves diet: lean meat, liver, kidney, seafood, and eggs contain more vitamin B12; Novel green leafy vegetables, cereals, liver, kidney and other animals have more net folic acid. 3 Give vitamin B12 and folic acid as prescribed by the doctor: Vitamin B12 is given intramuscularly and folic acid is given orally. 4 Those who have severe tremor should give a calming agent as prescribed by the doctor. For example, diazepam and other 5 family members accompanied by bleeding may take platelet reduction related methods. 1 Connect the clean skin, flat bed unit, soft bedding, loose wear, 2 gums and nasal cavity are the most common sites of bleeding, avoid using toothpicks to pick teeth and Brush your teeth with a hard toothbrush to prevent gum bleeding. Those with a dry nasal cavity can quietly rub the nasal cavity with a cotton swab dipped in a little paraffin oil. The humidity of the ward should be connected to the wet nasal mucosa. 3 Avoid eating raw, hard, fried, fried, and overheated foods. Provide soft and irritating foods to prevent mechanical or chemically irritating foods from damaging the mucosa of the digestive tract and bleeding. 4 Use injections as rarely as possible. Intramuscular injections are necessary. Or vein injection, on the one hand, you should use small needles as much as possible. After the injection, use a cotton ball to delay the time of pressing the needle eye to stop bleeding. When performing 5 bone marrow punctures, use dressings to pressure bandage and observe that the bleeding environment of the injection or puncture site may have heart failure. Correlative measures 1 The connection to the ward is quiet, the room temperature is suitable, the air is fresh, and the patient is half-sit. Resting in the supine or critical supine position is conducive to the recovery of cardiac function. 2 Adjust the oxygen flow according to the degree of hypoxia. 3 Reduce the body's oxygen consumption, reduce the net commitment of the heart, soothe and motivate the patient, help to establish the determination to defeat the disease, keep the patient's emotions unchanged, grant high protein, high vitamin, easy to digest and light diet, improve the nutritional status of the patient, a small amount of more Meals, avoid oversatisfaction, do not force stool, use laxatives when needed. 4 Nursing with diuretics When using potassium-releasing diuretics such as hydrochlorothiazide and furosemide, pay attention to the patient's indication of low potassium such as fatigue, abdominal contraction, and weakening of bowel sounds. The use of diuretics should be night or day It is advisable to avoid frequent urination at night and affect the rest of the patient. Definition of heart rhythm abnormality syphilis: caused by Treponema pallidum, with vulva corruption, external rash, pain and grief of bones and bones, skin nucleus and festering, air dementia as secondary epidemic. Clinical presentation Acquired dominant syphilis 1.1 Phase I syphilis: A marked clinical feature is Chancre. Common sites are:,, coronary sulcus, foreskin, urethral opening; size, cervical, anal canal, etc. Can also be found on the lips, tongue, breasts, etc. The characteristics of hard chancre are: 7 to 60 days after TP infection. Most patients have single ulcers, no pain, no itching, round or oval, clear ulcers, and the ulcers are beyond the skin surface, which is relatively clean. There are many excreta from secondary infectors. Touching cartilage-like hardness. It lasts for 4 to 6 weeks and can heal itself. Hard chancre can coexist with secondary syphilis. It is necessary to distinguish soft chancre, genital herpes, fixed drug rash and other local ulcerative lesions. Syphilis diaphragm: 1 to 2 weeks after the presentation of a hard chancre, department patients present with groin or guard lymph node swelling, which can be single or multiple. The swelling lymph node varies in size, hard, non-adhesive, non-destructive, Painless. It is called syphilis. 1.2 Second-stage syphilis: It is characterized by second-stage syphilis rash, which is symptomatic. TP occurs after the hard chancre decays or stacks, and TP spreads with blood circulation, which stimulates multiple lesions and multiple lesions. Skin, mucous membranes, bones, internal organs, cardiovascular, nervous system. When the syphilis enters the second stage, all the syphilis try-room diagnoses are positive. Just before the rash appears, fever, headache, sore joints, hepatosplenomegaly, and swollen lymphoma. The incidence is about 25% in men; about 50% in women. 3 to 5 days improved. Then presented syphilis rash, which has the characteristics of frequent occurrence. 1.2.1 Skin syphilis rash: Occurs in 80 to 95% of patients. It is characterized by diverse and frequent rash types, common and symmetrical, painless and itchy, leaving no scars after healing, expelling plums to cure agile decline, and rashes rich in TP. The secondary rash types are spot-like, pimples-like, pustular syphilis, genital warts, and palmar syphilis. 1.2.2 Recurrent syphilis rash: After the primary syphilis decays on its own, about 20% of patients with secondary syphilis will relapse within one year. Any symptoms of secondary syphilis can be presented from the beginning, with ring-shaped papules most common. 1.2.3 Mucosal damage: About 50% of patients present with mucosal damage. Occurred in the lips, various parts of the mouth, tonsils and throat, for mucosal plaques or mucositis, exudation or gray film, mucosal redness. 1.2.4 Syphilitic hair loss: about 10% of patients. Most of them are scarce and the gap is unclear, such as worm-eaten samples; a few are overflowing samples. 1.2.5 Bone and joint damage: periostitis, osteitis, osteomyelitis and arthritis. With pain and sorrow. 1.2.6 Secondary syphilis: Syphilitic iritis, iridocyclitis, choroiditis, retinitis, etc. Often bilateral. 1.2.7 Second-stage neurosyphilis: There are usually no symptoms, cerebrospinal fluid is very high, and cerebrospinal fluid is positive for RPR. May have symptoms of meningitis. 1.2.8 Secondary recurrent syphilis: Recurrent syphilis rash and mucosal damage are common, and there may be other damage. Symptoms are mild. 1.2.9 Superficial lymphocytic enlargement 1.3 Tertiary syphilis: Tertiary syphilis occurs in 1/3 of dominant TP infections. Among them, 15% are benign late syphilis, 15-20% are malignant late syphilis 1.3.1 Skin and mucous membrane damage: Nodular syphilis rash occurs frequently on the scalp, scapula, back and extremities of extremities. Gum swollen often occurs in the lower leg and is composed of deep ulcers and atrophic scars; when it occurs in the forehead, tissues are bad and perforated; those that occur in the middle of the nose are bones that constitute saddle noses; those of the tongue are Puncture ulcer; damage is ulcerative, which can constitute bladder leakage or ileum leakage. 1.3.2 near joint nodules: Subcutaneous fibrous nodules with delayed development of syphilitic fibroids. Symmetry, size, stiffness, Programs, no ulceration, normal epidermis, no inflammation, no pain, self-cancelling. 1.3.3 Cardiovascular syphilis: The secondary autonomic arch site occurs with automatic valvular insufficiency, which is syphilitic heart disease. 1.3.4 Neurosyphilis: The incidence rate is about 10%, and it usually occurs 10 to 20 years after TP infection. Asymptomatic, syphilitic meningitis, cerebrovascular syphilis, meningeal gum-like swollen, and sexual dementia can occur. Meningeal gum-like swelling involves lesions on one side of the cerebral hemisphere, with increased intracranial pressure, headache, and local brain symptoms. Natural neurosyphilis is a natural lesion of the brain or spinal cord. The former constitutes dementia, and the latter is expressed as degenerative changes of the posterior root and posterior cord of the spinal cord. Acquired syphilis acquired acquired TP after acquired TP and did not constitute dominant syphilis or the symptoms of syphilis temporarily decline after a necessary program period. Positive syphilis serum tests and cerebrospinal fluid examination were general, and acquired (hidden) syphilis was acquired. Within 2 years after infection, it is called late hidden syphilis; after 2 years after infection, it is called late hidden syphilis. Pregnancy syphilis Pregnancy or syphilis occurs during pregnancy. When pregnant with syphilis, TP can be passed to the fetus through the placenta or the umbilical vein and constitutes congenital syphilis in the currently born baby. The placenta tissue in pregnant women due to the occurrence of arteritis causes bad placenta, which results in miscarriages, premature births, and fetuses. Congenital Dominant Syphilis 4.1 Late congenital syphilis: The child is thin at birth, presents symptoms 3 weeks after birth, and has swelling and swelling, without adhesion, pain, and stiffness. More syphilitic rhinitis. About 6 weeks after birth, skin lesions are present, showing blister-bulous skin lesions (syphilis pemphigus) or maculopapular, papular scaly lesions. Osteochondritis and periostitis can occur. More liver and spleen enlargement. Thrombocytopenia and anemia. Neurosyphilis is rare. The expression of no hard chancre is one of the characteristics of congenital syphilis. 4.2 Late congenital syphilis: Occurrence is currently more than 2 years old. One type is eternal damage to bone, teeth, eyes, nerves, and skin caused by advanced lesions, such as saddle nose, Hao Qinsen's teeth, etc., which are not programmatic. The other category is still clinical manifestations caused by programmatic damage, such as keratitis, neurological deafness, abnormal nervous system expression, cerebrospinal fluid changes, hepatosplenomegaly, nasal or jaw gum swelling, hydrocephalus, periostitis, Inflammation and skin and mucous membrane damage. Congenital concealed syphilis has not been treated and has no clinical manifestations, but the serum response is positive. Those who are younger than 2 years of age are late congenital concealed syphilis, and those older than 2 years old are late congenital concealed syphilis. Definition of megaloblastic anemia:-A large cell anemia caused by lack of vitamin B12 or (and) folic acid, which is more common in infants. Clinical manifestations (1) General indications: pale and weak. The face is slightly edema, the hair is thin and yellow, and most of them are puffy. Susceptible to stomatitis. (2) The gastrointestinal tract indicates glossitis and pain and sadness of the tongue. The whole tongue is "fresh beef-like", the tongue nipples are atrophied and greasy; appetite loss, abdominal contraction, diarrhea, etc. (3) The nervous system shows that it is found in patients with vitamin B12 deficiency, especially pernicious anemia, with limb movements, weakness or antagonism, ataxia, feeling dull, urinary incontinence, impulsiveness, forgetfulness and metamorphosis.
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