护理导论案例（Introduction to nursing）.doc

护理导论案例（Introduction to nursing） Mr. Liu, 78 years old, for medical diagnosis in children accompanied by wheelchair admitted: pneumococcal pneumonia, complained of chest pain, chest pain, cough for a week, recently intensified, breathing, difficult toexpectorate sputum viscous. Check: T 39.8, P 102 / min, R 26 / min, BP 110/89mmHg. Clear and dark complexion, with the spirit of the poor, irritable mood, sleep, eating, dressing, toileting needs someone to take care of, after admission as the doctor has given intravenous antibiotic. Nursing diagnosis: 1, ineffective airway clearance: difficult to expectorate sputum viscous and lung infection: 2, the body temperature is too high: T39.8 degrees C: and lung infection 3, pain: chest pain and difficult toexpectorate sputum viscous related 4, impairment of gas exchange: breathing, shortness of breath, and not easy to produce the thick sputum 5, anxiety: emotional irritability, not easy to sleep: with health threats 6, there is danger of suffocation and difficult toexpectorate sputum viscous related 7, lack of knowledge: lack of knowledge about lung infection Nursing plan: (nursing diagnosis / anticipated goal / nursing measures) 1. clearing the respiratory tract is invalid: it is associated with thick sputum, old age, and pain. Objective: the patient can have effective cough and expectoration within three days. Measures： 1 every 2 hours to assist patients to turn over, back. Atomization inhalation 3 times / day. Maintain proper temperature and humidity in the room. Encourage the patient to drink plenty of water. The guide and encourage patients to effectively cough, expectoration. The proper rest, maintain their strength, if necessary, nasal catheter suction. 2. hyperthermia: T39.8 degrees: associated with infection, and surgical trauma. Objective: the patient returned to normal within three days. Measures： To observe the changes of body temperature, T, P and R q4h were measured. Give the alcohol swab and re measure the body