| AIRWAY MANAGEMENT: NONINVASIVE INTERVENTION | 無創(chuàng)氣道護(hù)理介入 |
| Assessment | 評估 |
| 1. Assess for possible impairment of airway clearance: increased work of breathing or inability to clear copious or tenacious secretions by coughing. | 評估可能的氣道清理損傷：呼吸功增加，或無法清除或咳出粘液?！?/td> |
| 2. Observe for signs of airway obstruction. | 觀察氣道梗阻體癥 |
| 3. Assess client's baseline knowledge of positioning, CPAP/BiPAP, and PEFR. | 評估病人體位、穩(wěn)定氣道正壓/雙水平式呼吸道正壓和呼氣流速峰值知識(shí)。 |
| 4. Review physician's order for CPAP/BiPAP and predicted values for PEFR. | 核對醫(yī)囑及預(yù)期值，檢查CPAP/BiPAP和PEFR?！?/td> |
| Implementation | 實(shí)施 |
| 1. Use Standard Protocol. | 使用標(biāo)準(zhǔn)儀式 |
| 2. Correct positioning of client: | 正確體位 |
| A. Sitting | 坐位 |
| 1. Semi-Fowler's or high Fowler's, sitting on side of bed, or in chair with elbows resting on knees. Clients with COPD may benefit from leaning over table with arms propped up. | 半坐臥位或高坐臥位，坐于床緣，或坐椅，兩肘置于膝蓋。慢性阻塞性肺病病人可背靠桌子。 |
| B. Standing | 站位 |
| 1. When client who is ambulating experiences shortness of breath or the need to cough, encourage a position that supports client. | 當(dāng)病人走動(dòng)時(shí)氣促或要咳嗽時(shí)，可倚靠物體 |
| C. Supine | 仰臥 |
| 1. Determine if two pillows or flat is more comfortable for client. Turn at least every 2 hours to encourage secretion drainage. Consider maneuvers to drain areas of lungs with retained secretions by gravity if tolerated by client. If unilateral reexpansion is needed, have client lie with side requiring expansion up: "good side down, affected lung up." | 確定雙枕或平臥時(shí)病人是否更舒適。至少每兩小時(shí)翻身一次，促進(jìn)分泌物排出。病情許可時(shí)，可通過體位引流法使肺區(qū)分泌物排出體外。如需單側(cè)二次擴(kuò)張，可讓病人側(cè)臥：健側(cè)在上，患側(cè)在下?！?/td> |
| 3. Controlled coughing | 控制性咳嗽 |
| A. Place client in upright position. High Fowler's leaning forward, or with knees bent and a small pillow or hand to support the abdomen may augment expiratory pressure. | 病人坐直。身體前傾，或屈膝并將一小枕或用手頂住腹部，以增強(qiáng)呼氣壓，利于痰液咳出?！?/td> |
| B. Instruct client to take two slow, deep breaths, inhaling through the nose and exhaling out the mouth. | 指導(dǎo)病人先行2次慢、深呼吸，鼻吸口呼?！?/td> |
| C. Instruct client to inhale deeply a third time, hold this breath, and count to three; then cough deeply for two or three consecutive coughs without inhaling between coughs. | 指導(dǎo)病人第三次深吸氣，屏氣，數(shù)到三時(shí)連續(xù)用力咳嗽2－3次，咳嗽時(shí)不能吸氣。 |
| D. Instruct the client to push air forcefully out of the lungs. | 指導(dǎo)病人用力將肺內(nèi)空氣壓出 |
| 4. Apply CPAP/BiPAP: | CPAP/BiPAP應(yīng)用 |
| A. Position client. | 安置病人 |
| B. Position face mask or nasal mask tightly and adjust head strap until seal is maintained and client is able to tolerate. | 帶口罩或鼻罩，調(diào)整頭部綁帶，以密封、病人能耐受為宜?！?/td> |
| C. Instruct client to breathe normally. | 指導(dǎo)病人正常呼吸?！?/td> |
| D. Apply at ordered setting for prescribed length of time. | 遵守醫(yī)囑對環(huán)境及時(shí)間的規(guī)定?！?/td> |
| 5. Obtain PEFR measurements: | 測量PEFR |
| A. Instruct client about purpose and rationale. | 向病人講明目的及要求。 |
| B. Place client in an upright position. | 病人行直立位?！?/td> |
| C. Slide indicator to base of the numbered scale. | 將指針移到刻度底部?！?/td> |
| D. Instruct client to take a deep breath. | 囑病人深吸一口氣?！?/td> |
| E. Have client place meter mouthpiece in the mouth and close lips, making a firm seal. | 讓病人將計(jì)量器放入口中，緊閉嘴唇，使不漏氣?！?/td> |
| F. Have client blow out as hard and fast as possible through the mouth only. | 囑病人用力盡快用口呼氣?！?/td> |
| G. This maneuver should be repeated two additional times, with the highest number recorded. | 再做兩次，記錄最高值。 |
| H. If client is to record PEFR at home, have client demonstrate PEFR technique independently and assess ability to record PEFR accurately in a diary. | 如病人要在家中記錄PEFR，先讓病人獨(dú)立演示PEFR操作技術(shù)，評估病人準(zhǔn)確記錄PEFR能力。 |
| 6. Use Completion Protocol. | 使用標(biāo)準(zhǔn)完成儀式。 |
| Evaluation | 評價(jià) |
| 1. Observe client's body alignment and position whenever in visual contact with client. Reposition as needed, at least every 2 hours. | 隨時(shí)觀察病人體位，需要時(shí)應(yīng)重新放置，至少每2小時(shí)一次。 |
| 2. Monitor client's respiratory status. Auscultate lung sounds at least q8h. | 監(jiān)護(hù)病人呼吸狀況，至少每8小時(shí)聽診病人肺音一次?！?/td> |
| 3. Assess breathing during sleep with CPAP. | 評估病人睡眼呼吸及CPAP?！?/td> |
| 4. Monitor ABGs/pulse oximetry. | 監(jiān)護(hù)病人動(dòng)脈血?dú)?脈血氧測定。 |
| 5. Observe technique of client/family using equipment. | 觀察病人及家屬儀器使用技術(shù)?！?/td> |
| Identify Unexpected Outcomes and Nursing Interventions | 確認(rèn)意外結(jié)果及護(hù)理措施。 |
| Record and Report | 記錄和報(bào)告 |
| 1. Respiratory assessment and positioning of client. | 病人呼吸評估和體位?！?/td> |
| 2. Cough effectiveness. | 咳嗽有效性 |
| 3. Ability to perform PEFR and understanding of readings. | 實(shí)施PEFR及測定值理解能力?！?/td> |
| 4. Tolerance of mask, skin beneath mask, and feeling of rest. | 口罩、口罩內(nèi)皮膚和對受限的耐受性?！?/td> |
掃一掃立即下載
