护理实践护理诊断(英文)

1、呼吸whats upW -where is it? 在哪H -how does it feel? 感觉怎样A -aggravating and alleviating factors 加重和减轻的因素T timing 时间S severity 严重程度U -useful other data 其他有用信息P -patients perception of the problem 病人主观感受消化系统Nursing process of patients with upper respiratory tract disorders上呼吸道疾病患者的护理过程1 Acute pain related

2、 to gastric mucosal erosion急性疼痛与胃黏膜受侵蚀有关（1） ask patient to rate pain level on scale of 0 to 10 every 3hours and as needed（2） ask about for factors precipitating and relieving pain（3） ask patient to help identify techniques for pain relief（4） administer antiulcer medications as ordered （5） provide sm

3、all，frequent meals 4 to 6 times a day（6） encourage nonacidic fluids between meals2 Risk for injury related to complications of peptic ulcer activity such as hemorrhage and perforation有受伤的危险与消化性溃疡活动引起的出血穿孔等并发症有关（1） monitor for signs and symptoms of hemorrhage such as henmatemesis and melena（2） monito

4、r vital signs：blood pressure，pulse，respirations，and temperature（3） maintain intravenous infusion as ordered（4） monitor hematocrit and hemoglobin levels as ordered心血管系统Nursing process of patients with hypertension 1.Deficint Knowledge related to disease process and treatment regimen.知识缺乏与不了解疾病病程和治疗方案

5、有关(1) Identify patients readiness and ability.(2) Provide patient with information concerning disease process including risk factors ,complications , and treatment regimen.2.Potential for ineffective therapeutic regimen management related to complexity of therapy , cost of medications , lack of symp

6、toms, side effects of medications , need to after long-term lifestyle habits , normal blood pressure controlled by therapy.潜在的对治疗方案管理无效与治疗复杂性，药物开销，缺乏症状，药物副作用，需要调整长期生活方式，经治疗后血压正常有关。(1)Identify patients modifiable risk factors and lifestyle modification needs.(2)Identify factors that are barriers to p

7、atient complying with therapy.(3)Develop plan to overcome barriers. Make referrals as needed.(4)Assess ability to take medications daily : financially , obtaining refills , understandingdirections.(5)Teach patient take medications as prescribed and not to skip dosages.(6)Teach patient to change posi

8、tions slowly to prevent falls.呼吸系统nursing care plan for the patient with a lower respiratory tract disorder1.Impaired gas exchange related to decreased ventilation or perfusion.气体交换受损与通风减少或灌注有关(1) Assess lung sounds, respiratory rate and accessory muscles.(2)Observe skin and mucous membranes for cya

9、nosis.(3)Assess degree of dyspnea on a scale of 0 to 10,0=no dyspnea，10=worst dyspnea (4) Monitor for confusion or changes in mental status.(5)Monitor arterial blood gas values and pulse oximetry as ordered.(6)Elevate head of bed or help patient to lean on overbed table.(7)Position with good lung de

10、pendent“good lung down” (8)Administer supplemental oxygen at 2L/min unless ordered otherwise.(9)Place a fan in the patients room.2.Ineffective airway clearance related to excessive secretions.清理呼吸道无效(1)Assess lung sounds q4th and prn(2)Monitor amount, color, and consistency of sputum.(3)Encourage or

11、al fluids; use cool steam room humidifier.(4)Turn patient q2h or encourage to ambulate if able.(5)Encourage patient to cough and deep breathe every hour and prn.(6)Administer expectorants as orders.(7)If patients unable to cough up secretions, suction per instruction policy (8)Obtain order for chest

12、 physiotherapy or flutter valve if indicated.3. Ineffective breathing pattern related to anxiety and pain.低效性呼吸形态与焦虑疼痛有关(1)Assess respiratory rate,depth,and effort q4h and prn.(2)Monitor blood gas and oxygen saturation values.(3)Determine and treat the cause of ineffective breathing pattern.(4)Place

13、 patient in Fowlers or semi-Fowlers Position.(5)Teach patient ito use diaphragmatic breathing,with a regular 2 second in,4 second out pattern 4.Activity intolerance related to imbalance between oxygen supply and demand活动无耐力与供氧和需氧不平衡有关(1)Assess amount of activity the patient can tolerate without beco

14、ming short of breath.(2) Monitor vital signs and oxygen saturation with activities.(3)Allow patient to rest between activities. Bed rest may be necessary during the acute dyspnea.(4)Obtain bedside commod,shower chair,handheld showerhead if needed。(5)Obtain portable oxygen if patient is able to ambul

15、ate。(6)Allow uninterrupted rest night as much as possible。(7)Slowly increase activity as able.(8)Refer patient with chronic lung disease to a pulmonary rehabilitation program泌尿系统：nursing care plan for the patient with renal failure1.nursing diagnosis：excess fluid volume related to kidneys inability

16、to excrete water.体液过多与肾脏不能把水排出有关(1)monitor weight daily at same time; report gain of greater than 2 pounds, monitor intake and output.(2)monitor and report shortness of breath, tachycardia, cackles in lungs, frothy sputum, heart irregularities, hypotension, cold clammy skin.(3)watch for new onset of

17、 jugular vein distention with patients head raised to 30- to 45- degree angle.(4). monitor vital signs, including orthostatic blood pressure.(5).monitor for edema.(6).monitor activity tolerance.(7).monitor serum protein and albumin levels.(8).maintain sodium and fluid restrictions as ordered.(9).dev

18、elop a plan with specific allotted amounts of fluid at each meal and for medications. Teach patient importance of each.2.impaired skin integrity related to dryness，excess fluid，crystal deposits皮肤完整性受损与干燥、多余的体液、晶体存储有关(1).served skin for open areas and signs of infection.(2).bathe with tepid water,oil

19、s or oatmeal.(3).apply lotion to skin after bathing.3.Activity intolerance related to anemia secondary to impaired synthesis of erythropoietin by the kidneys.活动无耐力与肾脏红细胞生成素受损而引起的继发性贫血有关。(1).assess for pale mucous membranes and skin color, dyspnea，chest pain.(2).monitor hemoglobin, hematocrit。(3).wat

20、ch for signs of bleeding。(4).administer erythropoietin as ordered.assist with blood transfusion as necessary.协助输血(5.have patient space activities with rest periods.4.Risk for injury related to bleeding tendency from platelet dysfunction and use of heparin during dialysis, and tendency for gastrointe

21、stinal bleeding。有受伤的风险与由于血小板功能障碍、在透析中使用肝素和消化道出血引起的出血倾向有关。5.risk for infection related to impaired immune system function 有感染的危险与免疫系统功能受损有关（1）monitor for signs and symptoms of infection and report promptly to physician（2）protect patient from any source of infection, including infected roommates, visitors, or nursing staff（3）maintain skin integrity（4）staff and patient practice good hand washing technique（5）culture any suspected site of infection as ordered by physician（6）consult with physician abou