Liver cirrhosis patient's standard attends to _'s prevention and health care of the plan

Liver cirrhosis patient's standard attends to _'s prevention and health care of the plan
Liver cirrhosis one or several kinds causes of disease acts on a kind of common chronic, going on, filling the air hepatopathy that caused long-termly and repeatedly. There are systems that are given much trouble at clinic, with opening by the setting-up of liver function damage, splenomegaly, collateral circulation, the ascites, in order to behave mainly, often present serious complications such as digestive tract bleeding, liver encephalopathy, continue, take place and is infected with,etc. in later period. This disease does not have special treatment, the key lies in diagnosing in early days, and strengthen and generally treat to the cause of disease, make the condition relieve and lengthen it and compensate one; It is mainly a treatment to the ill to losing and compensating a patient, improve liver function and rescue complication. The common nursing question is as follows, malnutrition: Lower than organism requirement; Humoral and too many ' Ascites) ; There are humoral and insufficient dangers; Have the danger that the skin integrality is damaged; Potential complication --Have difficulty in breathing; Potential complication --The esthesia changes; Potential complication --Bleed.
Malnutrition: Lower than organism requirement
[Relevant factor ]
The liver supersession function fails.
Disgusting, vomit, apocleisis.
The bile is secreted insufficiently.
Digest the breath obstacle.
Diarrhoea.
[Mainly behave ]
It is weak to become thin, depression.
The serious one is bedridden.
The skin dries up, complexion is dark and dark and matt.
Edema, angular stomatitis, nyctalopia,etc..
[Attend to the goal ]
The patient obtains enough nutrition, is shown as edema or ascites disappears.
[Attend to the measure ]
Offer high heat, high protein, high vitamin, diet apt to digest, to the daily badly off one, and the association takes food.
Offer a neat, clean eating the environment, the appropriate colour, fragrance and taste of regulating the diet, in order to increase the appetite.
Take food, little, vomit getting frequent, follow the doctor's advice the intersection of vein and supplementary high heat and nutriment, such as amino acid, albumin,etc..
Liquid quantity of recording 24h and coming in and going out accurately.
Monitor indexes such as the weight, serum electrolyte,etc..
[Comment on especially ]
Change of the weight
24h comes in and goes out the liquid amount is balanced.
Electrolytic level of serum.
Humoral and too many ' Ascites)
[Relevant factor ]
The pressure of portal vein increases.
Low albumen blood disease.
The lymphocytic liquid of liver is turned into too much.
Then the sending aldosterone increases.
Secrete vasopressin, increase.
The blood of effective circulation is insufficient in capacity.
[Mainly behave ]
Abdominal distension.
The belly expands grandly, the belly wall is tightened shinily, like frog's belly.
The difficulty of walking, shortness of breath, having difficulty in breathing and sitting up straight and breathing.
Umbilical hernia.
[Attend to the goal ]
The ascites is reduced, the patient is shown as abdominal girth shrinks.
Patient's main suit self-care ability increases, the following bed, entering the lavatory, personal hygiene,etc..
[Attend to the measure ]
Pay less salt or on diet ' Sodium chloride is less than or equal to 2g/d) .
Limit in 1000ml about every day such as inflow, if have prominent the intersection of hyponatremia and disease, should restrict within 500ml strictly.
Assist its life to attend to to the patient whose self-care ability drops of daily life.
Follow the doctor's advice and use diuretic, observation of balanced and disorder of paying attention to the electrolyte.
Follow the doctor's advice and put the ascites, it is 4000-6000ml each time, the vein infuses albuminous 40g, and observe the patient's general situation at the same time.
Advise patients and measure abdominal girth and combine the record while equalling and lying every day, by finding out about the reduced situation of ascites.
Monitor A/G ratio, electrolytic equivalence of serum albumin, serum.
[Comment on especially ]
Intensity that abdominal girth narrows.
Indexes such as A/G ratio, albumin, electrolyte,etc..
There are humoral and insufficient dangers
[Relevant factor ]
Use diuretic.
The ascites is put in a large amount.
Bleed.
Vomit, apocleisis.
The liquid is insufficient in intaking amount.
[Mainly behave ]
Patient's main suit is thirsty, apt to dehydrate and solicit.
[Attend to the goal ]
It is taken in sufficiently that humoral, the patient has not dehydrated and solicited.
[Attend to the measure ]
Assess patient have thirst and mucous membrane dry and skin elasticity bad and eye socket sink etc. dehydrate and solicit.
Limit in 1000ml about every day such as inflow, if have prominent the intersection of hyponatremia and disease, should limit within 500ml strictly.
Assist its life to attend to to the patient whose self-care ability drops of daily life.
Follow the doctor's advice and use diuretic, observation of balanced and disorder of paying attention to the electrolyte.
Follow the doctor's advice and put the ascites, it is 4000-6000ml each time, the vein infuses albuminous 40g, and observe the patient's general situation at the same time.
Advise patients and measure abdominal girth and combine the record while equalling and lying every day, by finding out about the reduced situation of ascites.
Monitor A/G ratio, electrolytic equivalence of serum albumin, serum.
[Comment on especially ]
Intensity that abdominal girth narrows.
Indexes such as A/G ratio, albumin, electrolyte,etc..
There are humoral and insufficient dangers
[Relevant factor ]
Use diuretic.
The ascites is put in a large amount.
Bleed.
Vomit, apocleisis.
The liquid is insufficient in intaking amount.
[Mainly behave ]
Patient's main suit is thirsty, apt to dehydrate and solicit.
[Attend to the goal ]
It is taken in sufficiently that humoral, the patient has not dehydrated and solicited.
[Attend to the measure ]
Assess patient have thirst and mucous membrane dry and skin elasticity bad and eye socket sink etc. dehydrate and solicit.
Observe the physical sign of the life to change closely, find pulse is compressed littly, the heart rate is increased fast, shock and omen symptom such as cold sweat look pale, appear in time.
Set up the intravenous passway rapidly, infuse fast, in order to supplement the blood capacity; If erupt simultaneously and bleed, deal with according to bleeding regularly.
Monitor the changes of blood pressure, pulse, urine quantity.
[Comment on especially ]
Skin, mucomembranous humidity and elasticity.
Whether indexes such as blood pressure, pulse and urine amount,etc. are normal.
Have the danger that the skin is damaged completely
[Relevant factor ]
Jaundice causes skin pruritus.
Low albumen blood disease causes the whole body edema.
Malnutritive.
Lie in bed for a long time.
Quiet continuously to drip the pituitrin.
[Mainly behave ]
It is ruddy to press the place or puncture the skin of position, bedsore incident or organizing necrosis.
[Attend to the goal ]
Patient's skin keeps intact.
[Attend to the measure ]
Pay attention to skin of whole body, mucomembranous protection:
Underwear and nightdress had better cotton products, so as to thin, reduce the friction of the skin.
Assist patient gargle since morning, after the meal, sleep, bleed, fasting, and person who go into a coma finish oral cavity, attend to, the dry one of lip applies liquid paraffin to protect.
The woman patient pays attention to the sanitation and hygiene of the perineum department; When the man patient's scrotum edema is obvious, hold up with the gauze, it is broken and routed to defend.
The persons who lie in bed for a long time will stand up on time, and massage is pressed the place, the ones that keep sheet and clothes are neat.
To the patient of the serious pruritus
Prune the patient's nail, defend scratching and injuring the skin.
Disperse the patient's attention, such as talk with people, listen to the music, read newspaper,etc..
Follow the doctor's advice offer antipruritic, alleviate itching water wipe and the intersection of acetic acid and lead wash etc..
Low albumen blood disease person follows the doctor's advice and supplements the albumin.
Instil the patient of the pituitrin continuously, should observe and puncture ruddy, humoral oozing out, swelling of the position closely, change and puncture the position regularly. Should deal with the person who leaks liquid promptly, if some Procaine closes, scribbles and wipes, detoxifies No.2,etc..
Monitor bilirubin, serum albumin level.
[Comment on especially ]
Whether patient's skin, mucomembranous integrality are damaged.
Indexes such as bilirubin, serum albumin,etc..
Fifth, potential complication --Have difficulty in breathing
[Relevant factor ]
A large amount of ascites.
The lung is infected.
Liver encephalopathy.
[Mainly behave ]
Breathe and increase and have difficulty in breathing fast and out of breath, incidently.
[Attend to the goal ]
The patient is shown as breath is steady.
[Attend to the measure ]
Observe the frequency, rhythm, weight that the patient breathes and have oxygen deficiency to solicit.
Ascites getting obvious to offer half lie in the location, make the skin of diaphragm drop, reduce lung blood stasis, in order to lighten to have difficulty in breathing.
Persons who lie in bed for a long time, encourage its cough, pat the back in order to promote and arranges the phlegm effectively while standing up.
Hepatic coma patient present spitting blood, should go pillow lie while being flat, partial to hair side, prevent the vomit from sucking by mistake.
Keeping the respiratory tract unobstructed, the persons who have difficulty in breathing seriously suck the oxygen.
Monitor every index of analysis of vim and vigour.
[Comment on especially ]
Frequency, rhythm and depth which the patient breathes.
Whether have difficulty in breathing.
Intensity of having difficulty in breathing improvedly.
Whether the index of analysis of artery vim and vigour is normal.
Potential complication --The esthesia changes
[Relevant factor ]
Liver encephalopathy.
[Mainly behave ]
Slight personality and behavior change, if euphoric and excited or indifferent speak few, relieve the bowls sloppily dressedly and everywhere.
It is still accurate to answer the question, but it is unclear and relatively slow to vomit words.
Can have flapping wing ' Hit) Kind trembles.
[Attend to the goal ]
Assess patient's consciousness state.
Should have special messenger who accompanies to the patients of mental confusion, behavioral disorder, do the safe precaution measure well.
Going into a coma begins to prohibit to eat the albumen egg in several days, supply with heat 5.0-6.7kJ and sufficient vitamin every day, regard carbohydrate as the main food, can increase protein to 40-60g/d gradually after mind is clear.
Go into a coma the patient for the nastal feed liquid in order to ensure the supply of energy and nutrition.
Keep the stool unobstructed, reduce the absorption of ammonia, follow the doctor's advice and lead cathartic or keep enema by eating the vinegar, forbid alkaline soap liquid enema.
Follow the doctor's advice, use, fall the intersection of ammonia and medicine, protect the intersection of liver and medicine and intestinal antibiotic, careful to spend calm hypnotic.
Ammonia water is flat to monitor the blood.
[Comment on especially ]
Patient's consciousness level.
Ammonia water of blood is flat.
Potential complication --Bleed
[Relevant factor ]
Esophagus, fundus of stomach are variceal to break.
The mucous membrane of acute stomach is rotten.
Peptic ulcer.
[Mainly behave ]
Because diet improper suffering from cold etc. easy to send to bleeding.
[Attend to the goal ]
The patient does not have bleeding phenomenon.
Find the bleeding phenomenon in time.
Bleeding stops, the patient displays the physical sign of the life steadily.
[Attend to the measure ]
Short of the dreg, few fibrous diet, avoid fried, subcooling, overheated food.
Observe and spitting blood, relieve oneself etc. black.
If erupt simultaneously and bleed:
Advise patients and stay in bed, comfort patient, clear up the bloodstain by the bed and pour out and guide things in time, prevent from badly to stimulate and aggravate anxious and frightened mood.
Observe spittinging blood, black number of times, quantity, color, shape and time to relieve oneself closely, and record it in detail.
Follow the doctor's advice for infusion, blood transfusion, in order to supplement the blood capacity, prevent low blood capacity shock.
Follow the doctor's advice, use styptic pharmaceutical, such as pituitrin or so kind that make etc..
Monitor blood pressure, pulse, breathe, the intersection of mind and 1 per hour, monitor hemoglobin, the intersection of blood cell and the intersection of specific volume,etc. and index.
[Comment on especially ]
Whether the patient has bleeding phenomena.
Blood pressure, pulse, hemoglobin level.
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