肺部感染护理查房课件.pptx

1、 肺部感染病人肺部感染病人 -护理查房护理查房Five weeks of practice ended in this way,and my feelings can only be summed up in eight words,although hard,but very substantial.简要病史：l 患者以“脑出血康复期、肺部感染”为诊断于2016-11-09收入我院康复科，于12-07转入RICU进一步治疗。l 查体：T:37.2，P:109次/分，R:21次/分，BP：110/80mmHg；Five weeks of practice ended in this way,a

2、nd my feelings can only be summed up in eight words,although hard,but very substantial.患者神志清楚，无语言，左侧肢体肌张力1级，右侧肢体肌张力2级，全身肌肉明显萎缩，右巴氏征阳性，上臂肌围18.6cmFive weeks of practice ended in this way,and my feelings can only be summed up in eight words,although hard,but very substantial.带入气管切开，切口敷料干燥；空肠管置入95cm，胃管5

3、5cm；骶尾部可见陈旧性皮肤破损，予水胶体敷料保护。Five weeks of practice ended in this way,and my feelings can only be summed up in eight words,although hard,but very substantial.l既往史：脑出血，l个人史：无嗜烟酒l婚育史：已婚（丧偶）l过敏史：无Five weeks of practice ended in this way,and my feelings can only be summed up in eight words,although hard,bu

4、t very substantial.l初步诊断：l 1、脑出血康复期l 2、肺部感染l 3、气管切开术后l 4、腰椎横突综合征 l 5、痴呆l 6、锥体外系综合征等 Five weeks of practice ended in this way,and my feelings can only be summed up in eight words,although hard,but very substantial.Five weeks of practice ended in this way,and my feelings can only be summed up in eight

5、 words,although hard,but very substantial.Five weeks of practice ended in this way,and my feelings can only be summed up in eight words,although hard,but very substantial.护理诊断：1、清理呼吸道无效 与呼吸道炎症及无力咳痰有关2、气体交换受损 与肺部炎症有关3、感染 与肺部炎症有关 4、营养失调 低于机体需要量 与炎症消耗 摄入减少有关5、有皮肤完整性受损的危险 与长期卧床皮肤受压有关6、自理能力缺陷 与肢体活动受限有关 7

6、、潜在并发症：呼吸衰竭、压疮、窒息、深静脉血栓8、沟通障碍 与气管切开有关9、腹泻 与胃肠功能紊乱、肠内营养剂有关Five weeks of practice ended in this way,and my feelings can only be summed up in eight words,although hard,but very substantial.l1）环境：保持病室安静、空气新鲜流通，温湿度适宜；减少人员流动。l 2)气切护理：保持呼吸道通畅，及时吸出气管内分泌物，持续的湿化；防止切口感染，保持切口清洁，每天碘伏消毒，更换无菌纱布；预防脱管，注意调整系带松紧，吸痰时动作

7、轻柔。l 3）促进排痰，改善呼吸，遵医嘱给予祛痰药，雾化吸入和机械排痰，以稀释痰液，促进痰液排出，做好痰标本的留取化验。Five weeks of practice ended in this way,and my feelings can only be summed up in eight words,although hard,but very substantial.l4）机械吸痰：每次吸引的时间少于15s，两次抽吸的时间大于3min吸痰动作要迅速、轻柔，在吸痰前、中、后适当提高吸入氧的浓度，避免吸痰引起的低氧血症，严格无菌操作，避免呼吸道交叉感染。l5）用药的护理:遵医嘱给予抗生素、

8、化痰等药物，静滴，口服、雾化吸入，掌握疗效和不良反应。l6）观察病情 密切观察生命征变化，加强口腔护理，观察口腔黏膜情况，保持口腔清洁，观察患者痰液情况，保持呼吸道通畅。Five weeks of practice ended in this way,and my feelings can only be summed up in eight words,although hard,but very substantial.l 7）皮肤的护理：预防皮肤损伤，保持床单位、皮肤清洁，预防感染。定期翻身、减压，睡气垫床，经常更换体位每23小时翻身1次，加强营养支持。发现皮肤问题及时处理，可用泡沫敷料

9、或水胶体敷料保护。l 8)胃管护理：床头因抬高30到45，鼻饲服药时应将药片研碎，溶解后在注入，保持口腔卫生，鼻饲前要检查胃管确定在胃内、有无胃内容物，鼻饲量不宜过多。鼻饲间隙时间不应少于2小时。可以建议医生用促进胃肠蠕动的药物。Five weeks of practice ended in this way,and my feelings can only be summed up in eight words,although hard,but very substantial.护理措施：l9）腹泻的护理：严格记录病人排便次数、量、性状、患者每日入量，注意脱水征；给予少渣、低脂、易消化、低

10、纤维素的流食、半流食，避免生冷、刺激性食物；注意腹部保暖；应注意保护肛周皮肤清洁、干燥，便后使用软纸擦拭，每日用温水清洗肛门，并涂凡士林油保护皮肤。Five weeks of practice ended in this way,and my feelings can only be summed up in eight words,although hard,but very substantial.护理措施：l10）防护护理：病人应单独安置在隔离病室，在床尾做好接触隔离标识；限制病人家属探视，如必须探视，须穿隔离衣；在护理过程中应穿隔离衣、严格遵守无菌操作，在对患者实施护理操作前后严格执行

11、手卫生规范；手上有明显污染时应洗手，无明显污染时可用速干手消毒剂消毒防止交叉感染；当患者感染治愈，且连续3个标本(每次间隔24小时)培养均为阴性时，方可解除隔离。Five weeks of practice ended in this way,and my feelings can only be summed up in eight words,although hard,but very substantial.l11)空肠营养管的护理：每次喂养前查看刻度记录，判断管道是否在位；l b 每次喂养或用药前后都要用20ml（或根据残余量所需）温开水冲洗管腔；床头抬高30-45。l c 建议每4

12、个小时（不管是否喂养）都应以脉冲式冲洗管腔；l d 此管道仅限指定营养液使用（不能打粥、汤）；l e 妥善固定胃肠营养管，避免管道牵拉、扭曲、折叠、受压；l f 若因营养液堵塞，可用50左右的热水用注射器加压冲洗营养管，或用5%碳酸氢钠溶液、尿激酶溶液冲洗，有助于管内蛋白和纤维凝块的溶解。Five weeks of practice ended in this way,and my feelings can only be summed up in eight words,although hard,but very substantial.12）饮食护理：加强营养支持，指导家属准备高蛋白、高热量、高维生素流质饮食，由护士定时定量胃管内注入，给予患者高能量的肠内营养液，注意调配食物，以增强患者的抵抗力。Five weeks of practice ended in this way,and my feelings can only be summed up in eight words,although hard,but very substantial.