医院体检 案例析.docVIP

案例分析 報告者:SN 個案基本資料：，，，、，，Positive WBC 30 ul 252↑ 藥物 分類 藥名 作用 副作用 機轉 個案使用目的的成效 日期 抗生素/頭孢子類 Cefazolin sodium 500mg 1pc Q12H IV 治療呼吸道、，感受性感染引起的呼吸道感染症中樞神經系統用藥精神安定劑IMIPRAMINE 1pc QD PO 治憂鬱病、夜尿呼吸系統用藥／祛痰劑痰液溶解劑Ambroxol 1pc QID PO 去痰、黏液溶解 疲勞、口乾、便秘、排尿困難 具刺激分泌與溶解分泌物的特性，促使排除呼吸道內粘稠分泌物。Phenazopyridine HCL 1pc QID PO 治BPH引起的排尿疼痛，保護尿道黏膜 頭痛、肝功能異常 緩解其排尿頭痛。 9/23~迄今 護理問題 呼吸道清除功能失效/分泌物滯留 導因:呼吸道內痰液濃稠咳不出來 定義性特徵:偶發異常呼吸音(濕囉音)、痰液的產生、無效性咳嗽 目標: 9/24個案可自行將痰液咳出 措施: (a-1)教導正確深呼吸及有效咳嗽方式 (a-2)鼓勵個案多坐起活動. (a-3)予chest care (a-4)觀察個案使用IPPB及Triflow的使用方式 評值: 9/24個案可將痰液咳出，黃稠，量多 急性疼痛/手術傷口、、，。，。。。 Secretary, Conference in XX, harvested in the province, XX conference experience in the province can be copied, promotion, reference, prevention and control system set up in order to concentrate on economic construction. Secretary Mr Leahy pointed out that to maintain public safety as an important livelihood project of boundless beneficence, to build the safest, most stable provinces of Liaoning, to full accountability to public safety, to the unprecedented increase, improve focus on public safety leadership, combat effectiveness, execution. Secretary of Mr Leahys speech made a great adjustment, official documents issued after study and implementation of police. The provinces Assembly, is XX experience refined and sublimated once again, practice makes perfect, it hosted the XX meeting, provincial conferences, we have to do in promoting the Conference on public security of XX practice road, the road to success ... Yet. Now on behalf of my party Committee work reports to the General Assembly. 　　Report title: hearts of cohesion, enforce, implement, with the political advantage of the party organization to promote new developments. 2012 work recalled 2012 years, in Council party of right led Xia, team party insisted to Deng Xiao-pings theory, and three a representative important thought and science development views for guide, to construction harm