教学查房1幻灯片.pptVIP

护理措施  (nursing intervention) 4.必要时静脉输液补充营养。 Intravenous nutritional supplements when necessary. 护理评价  Nursing evaluation 能建立合理的饮食方式和结构，营养指标在正常范围内。 Can establish a reasonable diet and structure, nutritional indicators within the normal range. 五. 活动无耐力 Activity intolerance 护理诊断 (nurses diagnosis) 注意事项 (b) 严格限制各种甜食 (c) 按时进食 (a) 多食含纤维素高的食物 相关因素 : (Related factors) (1 )疲劳 ( fatigue) (2)呼吸困难 (difficulty breathing) (3)氧供与氧耗失衡 (imbalance between oxygen supply and oxygen consumption) 护理依据 Nursing basis 护理措施  (nursing intervention) （1）评估活动耐力 Assess activity tolerance 了解病人过去和现在的活动类型、强度、持续时 间和耐受力 Understanding the patient‘spast and present types of activities ，intensity, duration and tolerance  护理措施  (nursing intervention) （2）协助做好一般护理 To help make the general care ? 休息与活动: （Rest and activity) 舒适体位: (Comfortable position) 护理措施  (nursing intervention) （3）减少体力消耗 Reduce physical exertion 指导病人采取有利于气体交换又能减少能量消 耗的姿势 Guiding the patient to take that help of gas exchange and can reduce energy consumption 护理措施  (nursing intervention) （4）协助和指导病人生活自理: Patient self-care assistance and guidance在病人活动耐力可及的范围内，鼓励病人尽可能自理 in the range form patient‘s endurance encourage patients to take care of themselves as much as possible 护理措施  (nursing intervention) （5）病情观察 Condition observed 观察有无右心衰竭的表现：如心悸、胸闷腹胀、量减少、下肢水肿等 Observe whether the performance of right heart failure：such as palpitations, chest tightnessabdominal distension, decreased urine output, lower extremity edema （5）病情观察 Condition observed 观察有无肺性脑病的表现：如头痛、烦躁不安、神智改变等