甲状腺功能亢进症病人的护理NursingofHyperthyroidismPatients71讲解.pptx

甲状腺功能亢进症病人的护理

NursingofHyperthyroidismPatients广西卫生职业技术学院内科护理教研室

DepartmentofMedicineNursing,GuangxiMedicalCollege

?护理程序

?Nursingprocedure护理评估

NursingAssessment护理诊断

Nursingdiagnosis护理目标

Nursinggoals护理措施

Nursingmeasures护理评价

Nursingevaluation

?护理评估?

?NursingAssessment?1、病史

疾病起始时间、主要症状、应激因素、家族史、月经史1、Medicalhistory

Onsettime,mainsymptoms,stressfactors,familyhistory,menstrualhistory

?护理评估?

?NursingAssessment?2、身体评估意识精神状态、营养状况、皮肤粘膜、眼征、甲状腺、心脏、消化系统、骨骼、肌肉2.PhysicalassessmentConsciousness,mentalstate,nutritionalstatus,skinmucosa,eyesigns,thyroidgland,heart,digestivesystem,skeletalmuscle

?护理诊断

?NursingDiagnosis护理诊断/问题

NursingDiagnosis/Problem1、营养失调：低于机体需要量与代谢率增高、消化吸收障碍有关

Nutritionaldisorder:LowerthaningestionrequirementRelatedtoincreasedmetabolicrateanddigestionandabsorptiondisorders2、活动无耐力与蛋白质分解增加、甲亢性心脏病、甲亢性肌病等因素有关

Activityintolerance:Relatedtoincreasedproteolysis,hyperthyroidheartdisease,hyperthyroidmyopathyandotherfactors

?护理诊断

?NursingDiagnosis护理诊断/问题

NursingDiagnosis/Problem3、应对无效与性格情绪改变有关

Ineffectiveresponse:Relatedtopersonalityandmoodchanges4、焦虑与神经系统功能改变、甲亢所致全身不适等因素有关

Anxiety:Relatedtochangesinnervoussystemfunction,hyperthyroidism-causedgeneralmalaiseandotherfactors

?护理诊断

?NursingDiagnosis护理诊断/问题

NursingDiagnosis/Problem5、有组织完整性受损的危险与浸润性突眼有关

Riskofimpairedtissueintegrity:Relatedtoinfiltrativeexophthalmos6、潜在并发症：甲状腺危象

Potentialcomplications:Thyroidstorm

?护理目标?

?Nursinggoals?病人能恢复并保持正常体重

Patientbacktohealthandmaintainsnormalweight能逐步增加活动量，活动时无明显不适

Graduallyincreasetheamountofactivitieswithoutobviousdiscomfort能恢复并保持足够的应对能力

Recoverandmaintainadequateresponsecapability能保持情绪平和

Maintainemotionalpeace

?护理目标?

?Nursinggoals?能积极采取措施保护组织完整性

Takestepsactivelyfortissueintegritypreservation能主动避免诱发甲状腺危象的因素，或发生甲状腺危象能得到及时救治

Activelyavoidthefactorsthatcausethyroidstorm,orabletoprovidetimelytreatmentw