Ineffective clearance of the respiratory tract is associated with respiratory inflammation, viscous sputum, fatigue, chest pain, disturbance of consciousness and other causes of ineffective cough.about Respiratory Diseases...
1. Symptoms:
(1) Cough and expectoration:
Acute irritant dry cough - upper sensation
Cough + white foam or mucous sputum - slow branch
Cough + massive purulent sputum (three layers after rest) - bronchiectasis, pulmonary abscess
Cough + rusty sputum - lobar pneumonia
Cough + red-brown peptone-like sputum - Klebsiella pneumonia
Cough + purulent foul sputum - anaerobic infection
Cough + Chocolate Sputum - Amiba Pulmonary Abscess
Cough + pink foamy sputum - acute pulmonary edema
(2) Common nursing diagnosis
1). Ineffective clearance of the respiratory tract is associated with respiratory inflammation, viscous sputum, fatigue, chest pain, disturbance of consciousness and other causes of ineffective cough.
2). Anxiety is related to severe cough and poor sputum excretion, which affect rest, work and long-term cure.
3). The dangerous face with asphyxia is associated with increased respiratory secretions, inability to expectorate, and disturbance of consciousness.
(3) Nursing measures and basis
1). Cleaning the respiratory tract is ineffective
① The environment provides a clean and comfortable environment to reduce adverse stimuli.Keep indoor air fresh and clean, and maintain appropriate room temperature (18-20 C)
And humidity (50%-60%) to give full play to the natural defense function of the respiratory tract.
② Avoid inducements and pay attention to keeping warm.Avoid stimulation such as dust and smoke, and avoid strenuous exercise, entering and leaving public places with air pollution, etc.
③ Dietary nursing
④ Observe the condition
⑤ Prevent the spread of pathogens
⑥Promote effective expectoration
[1]Deep breathing and effective cough
[2] Humidification and aerosol chemotherapy
[3]Chest percussion and chest wall concussion
[4] Posture drainage
[5] Mechanical sputum aspiration
⑦Medication nursing
2). Anxiety
① Environmental introduction
②Building confidence
③Coping methods
3). Hazard of asphyxia
(2) Hemoptysis:
Blood-lined sputum - tuberculosis, early lung cancer
Whole mouth hemoptysis or massive hemoptysis - bronchiectasis, pulmonary abscess, hollow lung TB, mitral stenosis.
(3) Dyspnea:
Increased airway resistance - slow branch, bronchial asthma, emphysema
Limited lung expansion - pneumothorax, pleural effusion, intrathoracic space-occupying lesions
Left heart failure - pulmonary stasis
2. Impaired gas exchange
1) Serious patients should be placed in the intensive care unit.
2) Dietary care
3) Psychological nursing
4) Keep the respiratory tract unobstructed
5) Medication nursing
6) Observation of disease condition
7) Oxygen therapy and mechanical ventilation
(2) Intolerance of activity
1) Comfortable position
2) Respiratory training
3) Rest and activity
(4) Chest pain:
The lesion is caused when it affects the parietal pleura.
Sudden chest pain + dyspnea + dry cough - spontaneous pneumothorax
Chest pain + fever - lobar pneumonia, tuberculous pleurisy, pulmonary abscess
Chest pain + cough, expectoration, hemoptysis - tuberculosis, bronchiectasis, lung cancer
2. Signs:
Respiratory diseases The vast majority of eyes, touch, percussion, hearing can have corresponding signs
In addition, there are extrapulmonary signs: clubbing fingers, joint swelling and pain
III. Auxiliary examination:
_Blood examination: WBC, DC, ESR
_Antigen skin test: OT test, PPD test allergen test
_Sputum examination: culture, direct examination of bacteria, examination of Ca cells.
_X-ray examination: one of the most commonly used methods, can be used for chest X-ray, plain film, tomography, bronchography, computer tomography
_Bronchoscopy:
(5) Biopsy: lung biopsy, pleural biopsy, lymph node biopsy, indications
_Blood gas analysis:
(1) Blood PH value: normal value: 7.35~7.45
(2) PaO2: normal value: 95~100mmHg<60(8.0Kpa) is respiratory failure.
_PaCO2: normal value: 35~45 mmHg average 40, >50 (6.67 Kpa) for respiratory failure
