Unit 22 Shock
Shock is a life-threatening condition that occurs when cardiovascular system is unable to meet the oxygen and nutritional needs of the body’s cells and is usually reflected by a sudden drop in blood pressure. Common causes include inadequate cardiac output due to heart failure, a sudden loss of blood volume due to hemorrhage, or a sudden decrease in peripheral vascular resistance due to anaphylaxis.
Adult respiratory distress syndrome (ARDS), disseminated intravascular coagulation (DIC), and multisystem organ failure (MSOF) are three especially serious conditions that may follow a prolonged episode of shock.
The four shock categories are: (1) hypovolemic shock caused by a decrease in the circulating blood volume. Hypovolaemia normally results from a haemorrhage, which can be either internal, such as bleeding from the spleen, or external, for example, from trauma; (2) cardiogenic shock caused by cardiac failure; (3) extracardiac obstructive shock caused by a blockage of blood flow in the cardiovascular circuit outside the heart; and (4) distributive shock caused by excessive dilation of the venules and arterioles. Most cases of clinical shock show some components of each of these categories.
Symptoms will include one or more of the following:
Anxiety or agitation
Confusion
Pale, cool, clammy skin
Low or no urine output
Bluish lips and fingernails
Dizziness, light-headedness, or faintness
Profuse sweating, moist skin
Rapid but weak pulse
Shallow and rapid breathing
Chest pain
Unconsciousness
The aim of the care is to re-establish perfusion of the vital organs and to prevent the shock from progressing. Regular observations are essential; the frequency depends on the patient’s condition, but at a bare minimum they should be recorded half hourly. The nurse should check for any fall in blood pressure and changes in hear t rate, as well as the strength of the pulse, as a weak and thready pulse is indicative of shock. The patient should ideally be monitored for cardiac rate and rhythm, blood pressure, and pulse oximetry. The nurse should regularly assess the patient’s conscious level and assessment should be used in conjunction with the Glasgow coma score, with any deterioration reported immediately. The patient’s respiratory rate should be measured, and the depth and pat tern noted. High flow oxygen should be given to any patient in shock, so pulse oximetry and blood gases are taken to provide an assessment of the patient’s respiratory status. Nurses should observe for tachypnea and respiratory tiredness, as these indicate that the patient might require mechanical ventilation.
Patients in shock should be kept warm, but should not be warmed too quickly, as this will cause peripheral vasodilation and could cause hypotention.
Strict fluid balance is essential and any losses and inputs need to be recorded.
The patient should lie in flat in the acute stage of shock and regular positional changes should be given to monitor pressure areas and to prevent fluid from accumulating in the lungs.
Unit 25 Fever
Body temperature is the result of the balance between heat product ion and heat loss.
Normal oral body temperature in the adult ranges from 36. 7℃ to 37. 6℃ (98. 1℉ to 99 .6℉). A healthy person’s body temperature slightly increases during the day since the morning (from 6: 00 a. m.). The peak body temperature is reached at 6: 00 to 10: 00 p. m. and the lowest is between 2: 00 and 6: 00 a. m.
An elevation of temperature above normal is referred to as fever or pyrexia. According to the degrees of the temperature, fever is classified as low-grade fever, mild fever, moderate fever, and high fever. Temperate between 37.6℃～38.2℃ (99.8℉～100.8℉) is considered a low-grade fever, between 38.3℃～38.9℃(101℉～102℉) is considered a mild fever, and between 38.9℃～39.4℃(102℉～103℉) is considered a moderate fever. Anything around 39. 4℃(104℉) or above is considered a high fever , and delirium or convulsions may occur.
Symptoms of fever include chills, aching everywhere, listlessness, red cheeks, feeling hot or cold, etc, which vary depending on the stage of the fever.
During the onset of a fever, the major signs are chills, shivering, pallid skin, increased pulse rate, and rising rectal temperature even though skin reading is cool.
During the period of chills, provide additional bedclothes and note the onset and duration of the chill.
It is necessary to encourage the patient to increase fluid intake to prevent potential dehydration due to excessive fluid loss from diaphoresis.
In addition to monitoring the patient’s temperature, the nurse needs to assess the patient’s pulse and respirations.
Unit 28 Pneumonia
Pneumonia is an infect ion of the lung that affects 1 out of 100 people annually.
Pneumonia is not a single disease. It can have over thirty different causes. The most common ones include bacterial pneumonia, viral pneumonia, mycoplasma pneumonia, and pneumonia associated with aspiration of foreign substances.
Antibiotics as a form of pneumonia treatment can cure bacterial and mycoplasma pneumonia most of the time, but there is no effective treatment yet for viral pneumonia.
The nursing diagnosis for pneumonia includes impaired gas exchange, ineffective airway clearance, hyperthermia, ineffective breathing pattern, risk for fluid volume deficit, and activity intolerance.
Nursing goals for pneumonia are: promote rest, maintain patent airway, control fever, prevent dehydration, ease breathing difficulty, provide nutrition, monitor respiratory efforts, reduce anxiety and detect complications early.
Nursing care of all types of pneumonia is basically the same. The client needs rest to prevent exhaustion. Encourage the client to take more fluids to prevent dehydration. The nurse must organize her work so that she does not disturb the client unnecessarily. The patient must be turned and repositioned frequently to avoid pooling of secretion. Remove heavy clothing and blankets and give sponge bathing when the client is flushed with fever. Encourage the client to take more fluids to prevent dehydration. Vital signs and chest sounds are monitored to assess the progress of the disease and to detect early signs of complications.
Unit 29 Hypertension
Hypertension refers to a condition characterized by sustained elevation of systolic arterial pressure of 140 mmHg or higher, or a diastolic arterial pressure of 90 mmHg or greater, or both.
Hypertension is divided into two categories: essential (or primary) hypertension and secondary hypertension. Essential hypertension is a sustained elevation of blood pressure without any known cause for it. Secondary hypertension describes a variety of conditions in which elevation of blood pressure results from or is secondary to some other disorder.
Many hypertensive individuals are asymptomatic or have mild symptoms like headache, fatigue, insomnia, and nervousness. However, all have an elevated systolic or diastolic blood pressure, or both. If blood pressure is not controlled, it can lead to stroke, congestive heart failure, myocardial in farction, dissecting or rupture of an aortic aneurysm, and renal failure.
The following are common nursing problems and corresponding nursing measurements accompanying patients with hypertention.
Cardiac Output inadequate.
Potential Possibility of Injury.
Uncomfortable Pain.
Activity Intolerance.
Anxiety .
Knowledge Deficit.
Unit 30 Diabetes Mellitus
Diabetes mellitus is a metabolic disorder characterized by chronic hyperglycemia and caused by various pathogeny. Two major groups of diabetes mellitus are typeⅠ, insulin-dependent diabetes and typeⅡ, non-insulin-dependent diabetes mellitus.
Often, the signs and symptoms of diabetes are only temporary and disappear once the disorder is controlled or the cause eliminated. The three typical symptoms of diabetes mellitus are polyuria, polydipsia, and polyphagia. Additional symptoms include weight loss, weakness, thirst, fatigue, and dehydration. These signs and symptoms may have an abrupt onset in those with typeⅠdiabetes. Those with typeⅡdiabetes may have a more gradual onset of symptoms. The complications of diabetes mellitus include diabetic ketoacidosis, hyperosmolar, hyperglycemic nonketotic syndrome (HNKS), hypoglycemia, vascular disturbances, and neuropathies. The treatment of diabetes mellitus may involve one or more of the following: diet, exercise, insulin, and weight control.
As diabetes mellitus is a chronic disease, one or more family members may take some or all of the responsibility of the treatment regimen. To allow the client and family members time to understand material, nurses should plan a teaching program that presents material in small steps. Begin teaching by explaining diabetes: what it is, why treatment is necessary, and the various methods of treatment.
Unit 31 Hepatitis
Hepatitis is an inflammation of the liver. It is caused by viruses, bacteria, alcohol, drug abuse, some medicines, or serious harm to the liver. Hepatitis is a very serious health problem in parts of Asia, Africa, and the Caribbean. There are several different viruses which can cause viral hepatitis. They are hepatitis A, B, C, D, and E viruses. All of these viruses can cause acute, or short-term, viral hepatitis. Hepatitis B, C, and D viruses can also cause chronic hepatitis, in which the infection is prolonged, sometimes lifelong. Other viruses may also cause hepatitis, but they have yet to be discovered and they are obviously rare causes of the disease.
People get viral hepatitis in many ways. Usually, people get hepatitis A or hepatitis E by eating food and drinking water infected with hepatitis A virus (HAV) or hepatitis E virus (HEV). People get hepatitis B or C by having unprotected sex (having sex without using a condom) with someone who has hepatitis B or C, being transfused with blood that is infected with the virus, sharing needles with someone infected with the virus, being accidentally stuck by an infected needle or using tools that are infected with the virus for tattoos and body piercing, and a mother passing the virus to her child during the birthing process. People get hepatitis D only if they already have hepatitis B.
Hepatitis, in its early stages, may cause flu-like symptoms. These symptoms may include malaise (a general ill feeling), fever, muscle aches, loss of appetite, nausea, vomiting, diarrhea, and jaundice. Some people may have no symptoms at all and may not even know they’re infected. If hepatitis progresses, its symptoms begin to point to the liver as the source of illness.
All of hepatitis patients should avoid alcohol, as it can worsen liver disease.
Unit 32 Care of the Client with Surgery
Surgery is the use of instruments during an operation to treat injuries, diseases, and eformities.
Surgery is scheduled based on the urgency required for a successful outcome for the client. Emergent or immediate surgery is needed when life or limb is suddenly threatened and any delay in surgery would jeopardize the client’s life or limb. Urgent surgery is the need for an operation within24 to 30 hours. An elective surgery is one that can be planned and scheduled without any immediate time constraints. Optional surgery, such as cosmetic surgery, is done at the request of the client.
The purposes of surgery are to cure pathologies by removing abnormal t issues or secret ion, and repairing damaged structures or inborn defects, to diagnose, to slow the progress of pathologic process, and to relieve the undesirable symptoms. The surgical process threatens the client’s ability to meet basic needs.
There are three phases in the surgical process: preoperative, intraoperative, and postoperative. In the preoperative phase, the client undergoes a series of diagnostic tests and physical examinations to ascertain his or her present state of health. The nurse obtains a nursing history to determine the clients nursing care needs and to identify actual or potential negative health problems. All clients must sign an informed consent before any surgical process.
Preoperative teaching serves to help relieve the fears and anxieties of the client as well as provides the client with the basic skills needed during the postoperative period.
Final safety and preparatory checks are carried out on the day of surgery.
The intraoperative phase begins when the client enters the surgical suite. When the surgery is completed, the incision is appropriately dressed and the client is transfer red to the postoperative recovery room. Records of the client’s vital signs during surgery, medications received, blood transfused, and any other immediately pertinent information are transferred with the client. They provide data for comparison in the recovery room.
In the early postoperative period, the nurse assesses the passage and function of all drainage tubes and adjusts them as necessary. The client’s levels of orientation, consciousness and feelings are assessed. Because the client may still be very groggy, special measures must be taken to ensure safety.
As the initial postoperative period ends, the client begins to meet more of his or her own health care needs. Nursing actions are those that will help to maximize the client’s recovery and assist the client to attain the highest level of well being within the usual life setting.
Many new health behaviors may have to be learned during the postoperative period.
本文来源：https://www.2haoxitong.net/k/doc/ae2369e3172ded630b1cb6e8.html
文档为doc格式