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Back pain disease 2015 western medicine nursing plan and interpretation doc

Updated: 2019-09-12

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In the second quarter of 2015, the nursing results of lumbar intervertebral disc bulge were summarized and explained. I. Fundamental environment Lumbar intervertebral disc bulge is the first disease in the "disadvantaged disease western medical care plan" identified by our hospital. From April to June 2015, Dayi Orthopedic Hospital of Sichuan Province was using the "Lumbar Intervertebral Disc Herniation Western Medicine Nursing Program" to treat a total of 156 inpatients in the rehabilitation department, including 4 cases handled by the Western Medicine Clinical Pathway. The average patient was hospitalized. 13.5 days. The dialectical classification statistics are as follows: 4 cases of qi and blood stasis type. Secondary dialectical care methods used: general care, pain and sorrow assessment, drug delivery care, lying position care, emotional care, diet guidance, program guidance, health guidance, etc. Secondary Western medicine nursing techniques used: electro-acupuncture, massage, traditional Chinese medicine fumigation, moxibustion, traditional Chinese medicine rubbing, magnetic vibration heating, encapsulation, pack, traction, etc. Second, the interpretation of the use of the nursing plan environment (a) the use of the environment of secondary Western medical care methods 1, the use of the environment of the secondary dialectical method of care, the number of cases of the use of the environment, the number of cases of the dialectical method of care, the implementation of the percentage of back pain 4 general care 4 100% pain and sadness Assessment 4 100% Lying care 4 100% Health guidance 4 100% Emotional care 4 100% Food care 4 100% Program guidance 4 100% Dosing care 4 100% Lower limbs 3 General care 4 100% Pain and sadness assessment 4 100% Lying care 4 100% Health guidance 4 100% Emotional care 4 100% Dietary care 4 100% Program guidance 4 100% Dosage care 4 100% 2. Number of cases of minor symptoms in the use of western medicine nursing technology The number of cases in which western medicine nursing technology is implemented Percent Waist and Leg Pain 4 Electric Acupuncture 4 100% Massage 4 100% Moxibustion 4 100% Chinese Herbal Medicine 4 100% Traction 4 100% Chinese Herbal Scrub 4 100% Lower Limb 3 Chinese Herbal Smoker 3 100% Electric Acupuncture 3 100% Massage 3 100% Moxibustion 3 100% Traction 3 100% The most frequently used items in Western nursing technology are electro-acupuncture, massage, traction, followed by traditional Chinese medicine fumigation, moxibustion, and traditional Chinese medicine rubbing. Explain the reasons: 1. Electro-acupuncture, massage and traction can alleviate pain and sorrow. The obligation is to adjust the current, technique and code components according to the patient's infection. Therefore, the automaticity is high. 2, small wounds, less suffering, patients easily take over. 3. The use of materials and operation methods are simple, and the clinical practice is easy to implement. 4. In recent years, the country has vigorously grown western medicine skills and supported medical insurance policies, which has provided inadequate guarantees for the implementation of the above methods. (II) Analysis of compliance and stiffness 1. Number of cases of patients' compliance and stiffness to western medical nursing techniques (persons). Compliance (%) versus stiffness (%). Compliance department compliance or non-compliance. 4 4 (100%) 0 0 4 (100%) 0 0 Massage 4 4 (100%) 0 0 4 (100%) 0 0 Chinese medicine fumigation 4 3 (75%) 1 (25%) 0 3 (75% ) 1 (25%) 0 Moxibustion 4 2 (50%) 1 (25%) 1 (25%) 2 (50%) 2 (50%) 0 Traction 4 4 (100%) 0 0 4 (100%) 0 0 Chinese medicine rubbing 4 4 (100%) 0 0 4 (100%) 0 0 Western medicine nursing techniques with good compliance are electro-acupuncture, massage and traction. Explain the reasons: 1. Electro-acupuncture, massage, and traction can alleviate pain and sorrow. The duty is being adjusted according to the patient's infection. The current, technique, and weight are adjusted. Therefore, the automaticity is high. Small and easy for patients to take over. 3. The materials and operation methods are simple and easy to implement in clinic. 4. In recent years, the country has vigorously grown western medicine skills and supported medical insurance policies, providing inadequate guarantees for the implementation of the above methods. The patient's high-stiffness western nursing technology is electroacupuncture, massage and traction. Explain the reason: it can reduce the symptoms of neck and shoulder pain, waist and leg pain in patients, and other treatments have relatively good results, so the patient's care is also higher in stiffness. 2. The patient's rightness to health pointing is divided into three ways: 4 people (100%) are right; 0 people are generally wrong; 0 people are wrong. Explain the reason: first, the content of the health guidance in the clinical path implementation plan is clear and clear, which is convenient for the caregiver to control and clinical use; secondly, the caregiver is in the process of operating, strengthen the communication between the nurse and the patient, and see the condition more timely, detailed, Health education is becoming easier to understand, and patients can feel the professional skills and excellent work of nursing staff, which has won the trust of patients. (3) Obligatory Evaluation of Western Medical Nursing Program Obligatory evaluation of Western Medical Nursing Program is divided into four rules: 4 people with high applicability (100%); 0 people with strong applicability; 0 people with general applicability; 0 people who are not suitable for use . Elucidate the reasons; 1. The first is that the plan gives systematic and clear professional guidance on the common symptoms of each disease, medication care, health guidance, etc., so that the nursing staff understand that I am in the nursing of various diseases in Western medicine specialty. What to do and how to do it avoid the blindness and randomness of previous work. 2. The plan systematically combed the western medicine nursing techniques commonly used in the common symptoms of various diseases, and made clear the links such as: selection and attention matters, so that the use of western medicine nursing techniques became more standardized and scientific. 3. A standardized nursing standard for western medicine specialty has a major guiding significance for improving the business nature of general nursing staff and the ability of western medicine clinical nursing. (IV) Existing problems during implementation 1. Western medicine dietary care has not been put in place: Due to the inability of the canteen of our hospital to provide dialectical cooking with distinctive western medicine, the limitations of western medicine-style dietary care are at the level of health guidance. 2. Nursing results were evaluated by voluntary indecent feelings, and poor indecent goals supported. 3. The compliance of the department's western medicine nursing technology needs further demonstration: The moxibustion therapy in this program, because the irritating taste affects the patient's respiratory function and comfort, the traditional Chinese medicine fumigants can cause colds due to temperature differences, and the traditional Chinese medicine rubbing may give patients Clothing becomes contaminated and affects compliance with this practice. 3. Evaluation of nursing results (I) Evaluation of nursing results 1. Evaluation methods Secondary symptoms of lumbar disc herniation, such as low back pain, lower dial use of secondary dialectical nursing methods, and nursing results after western nursing techniques . 2. The evaluation scale divides the nursing results of symptoms into four rules: good, better, average, and poor. (2) Nursing results analysis The above evaluation methods and scales are used to evaluate the nursing results. The secondary nodes are: the improvement of symptoms and the implementation of relevant health education content as the secondary evaluation goals. The results of this care plan are elaborated as follows: Number of cases of minor symptoms Nursing results (%) Good Good Fair Poor Lumbar and leg pain 4 3 (75%) 1 (25%) 0 0 Lower limbs 3 2 (67%) 1 (33% ) 0 0 Through the development of dialectical nursing, western nursing techniques and health guidance, more than 80% of patients believe that the joint treatment of western medicine has excellent nursing results in improving the symptoms of lower back pain and lower discomfort. Case 1: Liu Yongcheng, male, 41 years old, was admitted to the hospital from v. "Frequently contracted pain in the left lower limb for 4 years, plus Shen with left lower limb numbness for half a month". After being admitted to the hospital, the patient complained that the patient had no obvious incentive to show pain in the waist and legs, and began to have pain. He was relieved after undergoing "physical therapy, oral medication and topical plaster" in the local clinic. However, the symptoms after frequent sitting can be relieved after treatment. Half a month ago, the patient suddenly showed pain and sadness in the waist and legs, as well as radiation pain in his left and left limbs. T: 36.7 < C, P: 78 times / minute, R: 19 times / minute, BP: 119 / 78㎜Hg, pain and sorrow score: 3 points, self-care ability score: 5 points. Admission diagnosis: ① Western medicine diagnosis: back pain (qi and blood stasis syndrome); ② Western medicine diagnosis: lumbar 4-5 disc herniation, according to "Western Nursing Program for Lumbar Disc Herniation", for patients with lower back pain, lower limb numbness Give pain and sadness assessment, understand the degree, nature and duration of pain and sadness, connect accurate work, livelihood and posture, avoid external and waist warmth, and implement electro-acupuncture, massage, moxibustion, traditional Chinese medicine fumigation, traction, traditional Chinese medicine After rubbing, the waist pain was relieved after five days. He continued to heal the lower limbs, numbness, and numbness after one week, and his symptoms disappeared. Case 2: Ling Qiang, male, 53 years old, was admitted to the hospital from v. "Frequently contracted pain in the left lower limb for 4 years, plus Shen with left lower limb numbness for half a month". After being admitted to the hospital, the patient complained that the patient had no obvious incentive to show pain in the waist and legs, and began to have pain. He was relieved after undergoing "physical therapy, oral medication and topical plaster" in the local clinic. However, the symptoms after frequent sitting can be relieved after treatment. Half a month ago, the patient suddenly showed pain and sadness in the waist and legs, as well as radiation pain in his left and left limbs. T: 36.7 < C, P: 78 times / minute, R: 19 times / minute, BP: 119 / 78㎜Hg, pain and sorrow score: 3 points, self-care ability score: 5 points. Admission diagnosis: ① Western medicine diagnosis: back pain (qi and blood stasis syndrome); ② Western medicine diagnosis: lumbar 4-5 disc herniation, according to "Western Nursing Program for Lumbar Disc Herniation", for patients with lower back pain, lower limb numbness Give pain and sadness assessment, understand the degree, nature and duration of pain and sadness, connect accurate work, livelihood and posture, avoid external and waist warmth, and implement electro-acupuncture, massage, moxibustion, traditional Chinese medicine fumigation, traction, traditional Chinese medicine After rubbing, the waist pain was relieved after five days. He continued to heal the lower limbs, numbness, and numbness after one week, and his symptoms disappeared. 53 years old, admitted to the hospital from v. "Frequently waist pain for more than six years, plus Shen with left lower limb for half a month". After being admitted to the hospital, the patient had no significant incentive to show back pain before 2 months ago. The symptoms were relieved after acupuncture and massage outside the hospital, but after frequent sittings, the back pain was frequent, and the latter was intermittently being treated in our clinic. Half a month ago, the pain increased and became tingling, accompanied by left lower extremity. The symptoms were mild at night, and the symptoms increased after sitting for a long time. T: 36.3 < C, P: 74 times / minute, R: 20 times / minute, BP: 132 / 78㎜Hg, pain and sorrow score: 5 points, self-care ability score: 5 points. Admission diagnosis: ① Western medicine diagnosis: low back pain (qi and blood stasis syndrome); ② Western medicine diagnosis: lumbar 5- 骶 1 disc herniation, according to the "Western Nursing Program for Lumbar Disc Herniation", for patients with lower back pain, lower limbs And pain and sadness assessment, understand the degree, nature, and duration of pain and sadness, connect accurate work, livelihood posture, avoid external and neck warmth, and implement electroacupuncture, massage, moxibustion, traditional Chinese medicine fumigation, traction, traditional Chinese medicine After rubbing, the neck pain was relieved after five days. After one week of treatment, the pain in the lower limbs and lower limbs was described, and the symptoms disappeared. Case 3: Wei Zifang, female, 72 years old, was admitted to the hospital from v. "Eight years of pain in her waist and left lower limb for eight years". Eight years ago after the patient was admitted to the hospital, the patient had no obvious reason to show pain and grief in the lower back and left lower limb, with contraction and pain in the left lower limb. He was undergoing infusion, acupuncture, and oral medication (specific ominous) in the local hospital.着 ease. There is no improvement after taking oral medication (specific details) in our outpatient clinic. Before 4 months, the patient had no reason to show pain and sadness in the waist and legs, and increased pain, tingling, day and night, and the symptoms were relieved after being hospitalized in our hospital, but the pain and sorrow were frequent. T: 36.4 < C, P: 74 times / minute, R: 20 times / minute, BP: 118 / 70㎜Hg, pain and sorrow score: 3 points, self-care ability score: 5 points. Admission diagnosis: ① Western medicine diagnosis: low back pain (qi and blood stasis syndrome); ② Western medicine diagnosis: lumbar 4-5 disc herniation, according to "Western Nursing Program for Lumbar Disc Herniation", given to patients with low back pain, lower limbs Evaluation of pain and grief, understand the degree, nature and duration of pain and grief, connect accurate work, livelihood posture, avoid external and waist warmth, and implement electro-acupuncture, massage, moxibustion, traditional Chinese medicine fumigation, traction, traditional Chinese medicine rubbing After five days, the lumbar pain was relieved. After one week of treatment, the pain in the lower limbs, hands and lower limbs was described, and the symptoms disappeared. Fourth, the interpretation of Western medicine nursing (I) Nursing difficulties due to the implementation of the plan of 4 cases of lower back pain, lower extremity patients through timely symptomatic treatment, the symptoms are relatively relieved, so this lecture did not report on the nursing difficulties in the plan. Please ask. (2) Analysis of nursing probation From the interpretation of nursing results, it can be seen that according to the doctor's dialectical treatment, it is necessary to perform dialectical care, which will definitely improve the clinical symptoms of patients, reduce complications and improve the quality of food. It is like relieving pain in the lower back and legs, lower limbs, pointing to the exact way of living, local warmth, connecting the axis when turning over, western medical exercises: Wu Qin Xi, electroacupuncture, massage, traditional Chinese medicine fumigation, traction, traditional Chinese medicine rubbing according to the doctor's advice Moxibustion can relieve pain and sorrow and reduce complications. The 4 patients treated with this program had good or better nursing results for pain and sorrow, and 4 patients accounted for 100%.

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