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儿科护理诊断及护理评价
$36.44
儿科临床护理工具书
《儿科护理诊断及护理评价》的编撰以综合性儿童医疗机构目前使用的护理诊断与计划相关文书为主要框架,同时参考儿科护理教材...
《儿科护理诊断及护理评价》的编撰以综合性儿童医疗机构目前使用的护理诊断与计划相关文书为主要框架,同时参考儿科护理教材、北美国际护理诊断,较全面地总结了儿科常见症状、气道及呼吸、组织灌注及循环、消化与排泄、神经与活动、泌尿与体液、营养与喂养、社会与心理共8个方面的护理诊断,在编撰护理措施时,参考了相关领域的指南并充分收集了临床医护人员的专业意见,使这本手册更加具有科学性和适用性。希望这本手册能为儿科护理人员的临床工作提供便利。
顾莺,女,副主任护师,硕士生导师。 1999年毕业于上海医科大学护理系获医学学士学位,2008年获复旦大学护理学院护理学硕士学位。现任复旦大学附属儿科医院护理部主任。
第1部分 儿科常见症状第2部分 气道与呼吸第3部分 组织灌注与循环第4部分 消化与排泄第5部分 神经与活动第6部分 泌尿与体液紊乱第7部分 营养与喂养第8部分 社会与心理
前 言护理诊断(nursingdiagnosis)是关于个人、家庭或社区现存的或潜在的健康问题以及生命过程的一种临床判断,是临床护理人员为达到预期结果制定护理计划的依据;是护理程序(nursingprocess)中重要环节。《儿科护理诊断及护理评价》的编撰以综合性儿童医疗机构目前使用的护理诊断与计划相关文书为主要框架,同时参考儿科护理教材、北美国际护理诊断,较全面地总结了儿科常见症状、气道及呼吸、组织灌注及循环、消化与排泄、神经与活动、泌尿与体液、营养与喂养、社会与心理共8个方面的护理诊断,在编撰护理措施时,参考了相关领域的指南并充分收集了临床医护人员的专业意见,使这本手册更加具有科学性和适用性。希望这本手册能为儿科护理人员的临床工作提供便利。
1.1疼痛1.1.1定义 因组织损伤所引起的不舒服的感受和情绪体验1.1.2护理措施1.根据____量表评估患儿疼痛程度 早产儿疼痛评分(PIPP) 脸、腿、活动、哭闹、安抚评估量表(FLACC) Wang-baker面部表情评估量表 视觉模拟评分量表(VAS)2.使用相同的疼痛评估量表复评估患儿的疼痛频率、强度、部位及伴随的症状并记录3.观察药物镇痛后是否有恶心、呕吐、呼吸抑制等不良反应4.评价非药物干预的有效性,及时调整镇痛策略5.评价药物干预的有效性,及时调整镇痛策略6.与患儿或家属共同制定疼痛管理目标和策略7.鼓励患儿采用想象、呼吸及肌肉放松等方法缓解疼痛8.采用鼓励、表扬的形式给予患儿心理安慰。9.体位护理:给予患儿舒适体位缓解疼痛10.提供疼痛管理的相关健康宣教材料11.提供动画片、玩具、放音乐、电子产品等分散患儿注意力方法12.提供辅助工具____减轻术后伤口张力 胸带 腹带 抱枕13.给予患儿口服20%-30%的葡萄糖水(适用于小于3个月的患儿)14.给予患儿口服24%的蔗糖水(适用于小于3个月的患儿)15.给予患儿母乳喂养16.给予患儿安慰奶嘴17.协助家属给予患儿袋鼠式护理18.给予患儿鸟巢护理19.给予患儿抚触20.执行____医嘱药物镇痛 对乙酰氨基酚(大于6个月患儿) 布洛芬(大于6个月患儿) 吗啡 芬太尼 舒芬太尼 其他21.指导患儿适量活动,但活动力度不可过大22.指导患儿咳嗽时按压伤口两侧,防止伤口张力增加23.指导患儿排便时保护伤口的方法,防止伤口张力增加24.指导父母陪伴患儿缓解疼痛25.教导家属疼痛管理的方法、意义及注意事项,减少误解26.指导患儿家属使用自控式镇痛泵27.通知医生28.管理患儿周围环境,减少声、光刺激缓解疼痛
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