冠心病的护理查房
入院时间：20xx年10月26日
床号：八床
患者姓名：康华
患者年龄：57
性别：女
住院号:0848032
责任护士：XXXX
查房内容:冠心病
简要病史：患者5余年前无明显诱因下出现突发胸闷、气促，伴大汗淋漓、呼吸困难、乏力，急至上级医院行介入检查，告知有心脏血管堵塞，未行支架，以后在上山、活动量增加时有胸闷、气促，无胸痛，休息后可缓解，入院前一天洗澡时出现胸闷、左下胸痛，伴大汗淋漓，呼吸困难，咳嗽、咳少量白色痰，来我院急诊，于对症治疗后缓解，为求进一步治疗，门诊拟“急性心肌梗塞，心源性哮喘，心功能IV级”收住。
入院查体T36.9 P80次/分 R22次/分 BP110/80mmHg 患者神志清，精神状态软，皮肤巩膜无黄染，浅表淋巴结未及，听诊肺部呼吸音清，双下肺有湿啰音，心律齐，心音低，心尖部可闻及2/6SM杂音，腹平软，肝脾肋下未及，无压痛反跳痛，双下肢无浮肿，双足背动脉搏动存。
诊治经过
10月5日入院给 予一级护理、吸氧、心电监护、利尿、抗凝、扩冠、保胃、降脂、通便治疗 必要辅助检查
明确诊断为“冠心病、急性前壁心梗、肺部感染” 各种认识型态
1.健康认识----健康管理型态
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有吸烟史、已吸23年，无饮洒史。
2.营养----代谢型态
患者平素胃纳好,无偏食，体形正常
3.排泄型态 患者平素大小便均正常
4.活动----运动型态
患者平素感活动后肢体乏力明显
5.睡眠-----休息型态 患者夜间睡眠好
6.认知----感知型态
患者听力、视力、记忆力正常，对疾病认识较少
7.角色----关系型态
医患,护患沟通正常,家庭和睦,邻里关系良好，病友关系融洽
8.自我感觉----自我概念型态
患者小学学历,自觉记忆力差，学习疾病知识有少许障碍
9.性----生殖型态 患者已婚 育有2女
10.应对----应激耐受型态
患者比较担心疾病预后情况
他的护理诊断是
? P1气体交换受损
? P2心输出量减少
? P3 焦虑
? P4自理能力缺陷
? P5潜在的并发症：心脏停搏、各种栓塞、心律失常等 P1 气体交换受损相关因素：与肺淤血、肺部感染有关 预期目标：患者呼吸平稳
护理措施：
1）保持病室空气新鲜
2）给患者取半卧位休息、持续高流量吸氧（面罩+鼻塞） 2
3）鼓励病人咳嗽、排痰、深呼吸， 促进痰液排出
4）于心理护理，以免焦虑和恐惧而过度通气
5）按医嘱给于化痰药
6）定时监测血气分析，体温的变化
评价：患者25日予改为3L/min鼻塞给氧
现在3L/min鼻塞给氧下平卧及床上活动时呼吸平稳 P2心输出量减少
相关因素：与心功能下降有关
预期目标：病人床上活动无不适感、生命体征基本正 常
护理措施：
1）保持病室安静，注意保暖，可取半卧位
或高枕卧位休息
2）饮食上要控制钠盐的摄入、宜低脂、高纤维、少量多
3）持续吸氧
4）按医嘱给于强心、扩血管药物
5）病情观察：心率、心律、肺底湿啰音、尿量的变化等 以及药物的作用与副作用。
评价：患者现在床上活动无诉明显的不适，24小时尿量在
1500ml以上，肺底湿啰音较前减少
P3 焦虑
相关因素：与担心疾病预后、介入治疗有关
预期目标：焦虑情绪减轻
护理措施：
1、评估患者焦虑的原因、程度
2、向患者做好入院宣教，疾病相关知识宣教，配合治疗 及护理的必要性，介入手术前后的配合等。
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3、多与患者交流，进行心理护理，请康复病友做现身说
法，鼓励家属多与患者沟通，建立信心，以减轻焦虑情绪。
4、必要时按医嘱使用镇静剂。
5、合理安排护理操作的时间，以减少对病人的打扰。
评价：患者焦虑情绪减轻，能积极配合治疗及护理
P4自理能力缺陷
相关因素：与疾病限制绝对卧床、乏力有关
预期目标：基本满足生活所需
护理措施：1）评估患者自理能力的程度
2）协助完成生活护理
3）置用物于患者易取之处
4）与患者一起制定活动计划，逐步恢复自理能力
评价：患者部分生活自理（如洗脸，穿衣等）
P5潜在的并发症
心脏停搏、各种栓塞、心律失常等
相关因素：与心功能下降、冠状动脉粥样硬化、心肌缺氧有关 预期目标：无并发症发生
护理措施：1）严密监测心电监护、生命体征的变化
2）密切监测病情变化，定时监测心功能、血 气分析、肾功能、血常规、血电解质等
3）按医嘱给予强心、利尿、扩血管等药物
4）准备好急救药物及设备
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Coronary heart disease nursing rounds
Admission time: October 26, 2012
The bed number: eight bed
Patient name: Hong Wah
Age: 57
Gender: Female
Admission number: 0848032
Liability nurses: Zhao Chunmiao
Rounds: coronary heart disease
A brief history : patients 5 years ago under no obvious predisposing causes sudden tightness in the chest, shortness of breath, with sweat, dyspnea, fatigue, anxious to higher hospital interventional examination, told of cardiac vascular congestion, without support, later in the uphill, activity increased with chest tightness, gas hurried, without chest pain, after the break remission, a day before admission chest tightness, take a shower when the left lower chest pain, with sweat, dyspnea, cough, a small amount of white sputum, to emergency department of our hospital, to symptomatic remission after treatment, for further treatment, clinic to "acute myocardial infarction, cardiogenic asthma, cardiac function class IV " live.
Admission examination T36.9 P80 / BP110/80mmHg R22 / min
Patients with Shen Zhiqing, mental state and soft skin, sclera yellow dye, superficial lymph nodes which, auscultation of the lungs breath sounds clear, double lung wet rales, rhythm, heart sound is low, the apex of the audible and 2/6SM murmur, plain abdominal soft ribs, and not without tenderness, rebound tenderness, double lower limbs no edema, double the dorsalis pedis artery pulsatility deposit.
After treatment
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In October 5th admitted to a level of care, oxygen inhalation, ECG monitoring, diuresis, anticoagulation, crown expansion, protecting stomach, lipid-lowering, laxative treatment necessary auxiliary examination
For the definitive diagnosis of coronary heart disease ", anterior wall acute myocardial infarction, pulmonary infection "
All kinds of styles
1 health awareness, health management pattern
With a history of smoking, smoking 23 years already, no alcohol drinking history.
2 nutrition, metabolism pattern
Patients usually appetite is good, no partial eclipse, with normal body weight 3 excretion pattern in patients with usual size they are normal
4 - sports types
Patients usually are activity obviously physically weak
5 - rest sleep pattern in patients with nocturnal sleep well
6 cognitive - perception
Patients with hearing, eyesight, memory, knowledge on the disease less The 7 part ---- the relationship type
Patient, nurse-patient communication, family harmony, neighborhood relationship, patient harmonious relationship
The 8 sense of self, self concept type
Patients with primary school education, perceived poor memory, learning and knowledge of disease have some obstacles
9 - reproductive pattern in patients with married and had 2 children
10 - stress coping style
Comparison of patients with fear of disease prognosis
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His nursing diagnosis
P1 impaired gas exchange
P2 decreased cardiac output
P3 anxiety
P4 self-care ability defects
P5 potential complications: cardiac arrest, various embolism, arrhythmia P1 impaired gas exchange factors associated with pulmonary congestion, pulmonary infection: relation
Objectives: Patients with breathing.
Nursing measures: 1 ) keep ward air fresh
2) to patients to take half of supine rest, continuous high flow oxygen ( mask + nasal congestion )
3) to encourage the patient cough, expectoration, deep breathing, facilitating sputum discharge
4) in psychological nursing care, to avoid anxiety and fear and hyperventilation
5) according to the doctor's advice to and expectorants
6) regular monitoring of blood gas analysis, temperature change
Evaluation: 25 patients to change to 3L/min nasal oxygen
Now 3L/min nasal oxygen under horizontal and bed activity when breathing. P2 decreased cardiac output
Factors associated with decreased cardiac function related to:
Objectives: patient bed activity no discomfort, it is basic and vital signs Often
Nursing measures: 1 ) keep quiet ward, pay attention to keep warm, desirable semi recumbent position
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Or high pillow supine rest
2) diet to control salt intake, low fat, high fiber, suitable for small
3) continuous oxygen inhalation
4) according to the doctor's advice to the strong heart, vascular dilation drug
5) observation: heart rate, cardiac, lung crackles, urinary volume changes. As well as drug effects and side effects.
Evaluation : the patient bed now no v. obvious discomfort, 24 hour urine output in
1500ml above, the bottom of lung wet rale earlier reduction
P3 anxiety
Factors associated with the prognosis of the disease: worry about,
interventional therapy
Target: anxiety relief
Nursing measures:
1, to assess the cause of anxiety, degree
In 2 patients, to make the hospital education, disease related knowledge propaganda, with the treatment of
And the nursing care before and after interventional operation, coordination. 3, how to communicate with patients, psychological care, rehabilitation patients do appear that please
Method, to encourage families to communicate with patients, to establish confidence, to relieve anxiety.
In 4, when necessary, by a physician use tranquilizer.
5, reasonable arrangement of nursing operation time, reduces to the patient. Evaluation: in patients with anxiety relief, to actively cooperate with treatment and nursing
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P4 self-care ability defects
Factors associated with disease limits: absolute bed rest, related to the weakness of
Objectives: to meet the basic needs
Nursing measures: 1 ) to assess the degree of self-care ability of patients
2) to assist the completion of life care
3) a matter to patients are easy to take place
4) and patients together to plan the activities, and gradually resume the self-care ability
Evaluation of patients with partial: self-care ( such as face, clothing etc ) P5 potential complications
Cardiac arrest, a variety of embolism, arrhythmia
Factors associated with functional decline: heart, coronary atherosclerosis, myocardial hypoxia
Target: without complication
Nursing measures: 1 ) close monitoring of ECG, the changes of vital signs
2) closely monitoring the condition changes, regular monitoring of heart function, blood gas analysis, renal function, blood routine, blood electrolyte
3) according to the instructions given the strong heart, diuresis, vasodilator agents
4) ready for emergency medicine and equipment
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