课件：室间隔缺损护理查房_-_副本.ppt

室间隔缺损的护理;定义（definition ） ;病因( Pathogeny) ;分类（classification ）;病理生理（Pathophysiology ）;;临床表现（clinical manifestation ）;2、体征(signs )： （1）心前区轻度隆起 The area before the heart?slightly elevated （2）胸骨左缘3-4肋间闻及3级以上粗糙响亮的全收缩期杂音。 Left parasternal?intercostal? can ?heard? ?3-4?and?more than 3?rough?loud?holosystolic murmur. （3）发育迟缓和不良 Growth retardation?and poor ;辅助检查(laboratory?examinations? );2、X线检查(x-ray examination );3、超声心动图(echocardiogram ) ;治疗(treatment );治疗(treatment );3、严重肺动脉高压、有右向左逆向分流者，禁忌手术。 patient who have a severe pulmonary hypertension, ?right to left?shunt?operation?in reverse can not operate. ;护理问题(Nursing problems );术后(postoperative )： 1、有心输出量减少的危险(risk of decreased cardiac output ) 2、清理呼吸道无效 （clear?the?airways invalid） 3、舒适度改变 （the?change of comfort? ） 4、有皮肤完整性受损的危险 (impaired skin integrity?is invalid ) 5、潜在并发症（the potential complications ）：肺高压危象、心律失常 ;护理措施nursing measures;术前（Preoperative）; 2、护士应该热情接待患者，做好入院宣教，消除患者的陌生感。 The?nurse should?recept warmly ,?do a good?admission education so that they ?eliminate the strangeness. ;3、病房开窗通风，患者注意保暖,减少人员探视，避免呼吸道感染。 we should ventilat windows in the ward， patients?pay attention to keep warm ,reduce personnel visit to prevent?respiratory infection.;4、向患者及家属讲述术前的注意事项置管情况，并介绍手术室及监护室的一些情况。 Tell patient and their families about the attention to?the wound?and catheter or some?condition about operation room and ?intensive care unit;术后(postoperative )：;2 保持呼吸道通畅,术后应用呼吸机辅助呼吸,保持患儿四肢温暖，促进末梢血液循环. Keep airway clear, apply ?ventilator assisted breathing and keep warm to promote the blood circulation ;3、 采用体位引流，采取体疗促进痰液排出，遵医嘱用药，必要时进行吸痰。 take postural drainage and physical therapy to?promote?sputum discharge,?sputum suction?if necessary. ;;4、观察疼痛的性质，持续时间，给予患儿舒适的体位，必要时遵医嘱给予药物止痛。 Observe the?nature of pain,?duration,?and give patient ?a comfortable posture,?when is necessary give?drug at the doctors advice? . 5、预防发生肺高压危象 prevent pulmonary?hypertension