First, anxiety.
Related factors:
1. I don't know the course of disease and treatment plan.
2. Not familiar with the hospitalization environment.
Main performance:
I'm afraid my illness is intractable, I lack self-confidence, I don't want to face the reality, I'm fidgeting, and I can't sleep.
Nursing objectives:
The patient's anxiety eased.
Nursing measures:
1. Understand patients, listen to patients patiently and give guidance.
2. patiently explain the condition and treatment plan, so that patients can cooperate with the treatment with peace of mind.
3. Politely explain the influence of anxiety on physical and mental health to patients, and encourage patients to put down their ideological burdens and face the reality bravely.
4. Give affirmation and encouragement to patients' cooperation and progress, and enhance their confidence in treating diseases.
5. Create a quiet and comfortable hospitalization environment.
Key assessment:
1. Whether the patient's mood is stable and whether he can actively cooperate with the treatment.
2. Whether the patient's sleep quality has improved.
Second, self-care defects
Related factors:
1. The lesion invaded the striated muscle.
2. Hypokalemia:
Main performance:
Patients feel weak in lower limb muscles, and it is difficult to stand up and lift their upper limbs after sitting down.
Nursing objectives:
The patient's daily life is satisfied.
Nursing measures:
1. Ask the patient to stay in bed in the acute phase.
2. Put the items frequently used by patients in places that are easy to take and put, so as to reduce physical consumption.
Put the pager at the patient's hand and help him when he hears the call.
4. Implement life care during bed rest: assist patients to eat in bed, wash clothes, urinate, etc.
5. People whose condition permits should be encouraged to do appropriate activities, such as combing their hair, squatting down, holding fitness balls, etc. But they should avoid overwork.
6. During the treatment, observe whether the patient is potassium deficient: abdominal distension, muscle weakness, etc.
7. Apply high-dose hormone and supplement potassium according to the doctor's advice.
Key assessment:
1. Whether the living needs of patients are guaranteed.
2. Observe whether the patient has signs of potassium deficiency.
Third, there is a risk of dysphagia
Related factors:
Muscular diseases of throat, esophagus and palate.
Main performance:
Swallowing reflex is weakened, eating is difficult and the voice is hoarse.
Nursing objectives:
Eat freely and pronounce normally.
Nursing measures:
1. When you are hoarse, you can talk with pen and paper or sign language.
2. If you have difficulty swallowing, you should follow the doctor's advice for intravenous rehydration and strengthen nutrition.
3. If necessary, take nasal feeding with high protein, high calorie and high quality inspection, and collect a lot of liquid food.
4. If the swallowing function is restored, you can gradually give semi-liquid and soft food, and ask the patient to eat, and the speed should not be too fast.
Key assessment:
1. Whether the swallowing function of patients has improved.
2. Whether the patient's pronunciation is normal.
Fourth, there is a danger of difficulty breathing.
Related factors:
Diaphragm and respiratory muscles are involved.
Main performance:
Shortness of breath, hypoxia and even respiratory failure.
Nursing objectives:
1. The patient's breathing keeps normal function.
2. No respiratory failure.
Nursing measures:
1. Let the patient take a semi-sitting position according to the condition; Assist the life care of patients.
2. Observe the patient's respiratory rate closely, and report to the doctor immediately if any abnormality is found.
3. When the patient has acute dyspnea, the nurse will wait at the bedside and take oxygen according to the doctor's advice.
4. When necessary, prepare rescue instruments and articles at the bedside, such as ventilators and rescue drugs.
5. Prepare tracheotomy and bandage it at the bedside.
Key assessment:
1. Whether the patient's breathing frequency is normal.
2. Whether hypoxia has improved.