1、内科疾病护理常规

内科疾病护理常规目录1、内科疾病一般护理常规······································12、呼吸系统疾病一般护理常规··································23、慢性支气管炎护理常规······································34、肺炎护理常规··············································45、支气管哮喘护理常规········································56、支气管扩张护理常··········································77、自发性气胸护理常规········································88、呼吸衰竭护理常规··········································99、循环系统疾病一般护理常规································1110、慢性心力衰竭护理常规····································1211、心律失常护理常规········································1412、病毒性心肌炎护理常规····································1613、感染性心内膜炎护理常规·································1814、心肌病护理常规··········································2015、冠心病护理常规··········································2216、心绞痛护理常规··········································2417、心肌梗死护理常规········································2618、心脏瓣膜病护理常规······································2819、高血压病护理常规········································3020、慢性肺源性心脏病护理常规································3221、消化系统疾病一般护理常规·······························3322、慢性胃炎护理常规········································3423、消化性溃疬护理常规·····································3524、胃癌护理常规············································3725、肝硬化护理常规·········································3826、肝性脑病护理常规········································4027、急性胰腺炎护理常规······································4228、上消化道出血护理常规····································4429、肠结核护理常规··········································4630、溃疡性结肠炎护理常规····································4731、结核性腹膜炎护理常规····································4932、泌尿系统疾病护理常规···································5133、急性肾衰竭护理常规······································5234、慢性肾衰竭护理常规······································5335、急性肾小球肾炎护理常规··································5536、慢性肾小球肾炎护理常规··································5737、肾病综合征护理常规······································5938、尿路感染护理常规········································6139、血液及造血系统疾病一般护理常规··························6240、缺铁性贫血护理常规······································6341、再生障碍性贫血护理常规··································6442、出血性疾病护理常规······································6543、白血病护理常规·········································6644、化疗病人护理常规·······································6745、骨髓移植病人一般护理常规·······························6846、骨髓移植病人无菌护理常规·······························7047、内分泌系统疾病一般护理常规·····························7148、甲状腺功能亢进症护理常规·······························7249、甲状腺功能减退症护理常规·······························7450、糖尿病护理常规·········································7651、皮质醇增多症护理常规···································7852、原发性醛固酮增多症护理常规·····························7953、嗜铬细胞瘤护理常规·····································8154、痛风护理常规···········································8255、肥胖症护理常规·········································8456、尿崩症护理常规·········································8557、系统性红斑狼疮护理常规·································8658、类风湿关节炎护理常规···································8859、多发性肌炎、皮肌炎护理常规·····························9060、系统性硬化病护理常规···································9261、强直性脊柱炎护理常规···································941一、内科疾病一般护理常规1病人入院后由接诊护士根据病情安排床位，及时通知医生，协助体检，新入院病人建立护理病历，并做好入院介绍。2新入院病人由责任护士测量体温、脉搏、呼吸，以后每天测量4次，连续3天；体温正常者改为每天1次；体温超过37.5℃的病人每天测量4次；体温超过39℃者，每4小时测量1次，持续观察72小时。3按医嘱给予饮食，指导病人按需进食，危重病人必要时给予鼻饲饮食。4动态观察病情变化，认真听取病人主诉，注意观察分泌物、排泄物的变化以及药物作用、不良反应。5新入院病人遵医嘱次日晨留取血、尿、粪常规标本并送检。6每日记录粪便次数1次，便秘病人，遵医嘱绐予轻泻药或进行灌肠等处理；每周测体重1次，并记录在体温单上。7准确、及时执行医嘱，确保各项治疗计划落实。8根据病人病情及生活自理能力的不同，给予分级护理，落实基础护理，危重病人做好重症护理，预防压疮、呼吸系统及泌尿系统感染等并发症的发生，做好安全防护。9.开展健康教育，针对病人及家属需求进行健康指导，如疾病防治、饮食及用药指导、心理护理等。2二、呼吸系统疾病一般护理1按内科疾病病人的一般护理。2休息与体位：重症病人应绝对卧床休息，轻症或恢复期可适当活动。3饮食护理：高蛋白、高热量、高维生素、易消化饮食，多饮水。4遵医嘱给予氧气吸入，注意观察氧疗效果，5保持呼吸道通畅，指导病人正确咳嗽、咳痰，必要时给予吸痰。机械通气病人做好气道管理。6严密观察神志、生命体征变化，如出现呼吸困难加重、剧烈胸痛、意识障碍咯血等应立即通知医生并配合抢救。7准确落实纤支镜等各项检查的术前准备．并做好术后观察及护理。8观察药物疗效及不良反应，如有无血压升高、脉速、肌肉震颤等，发现问题及时通知医生处理。9危重病人做好重症护理。10做好心理护理及健康指导。3三、慢性支气管炎的护理常规慢性支气管炎(chronicbronchitis)简称慢支，是指气管、支气管黏膜及其周围组织的慢性非特异性炎症。临床上以咳嗽、咳痰或伴有喘息及反复发作的慢性过程为特征。1按呼吸系统疾病病人的一般护理。2休息与体位：加强病人休息，注意保暖。3饮食护理：营养丰富、易消化饮食和，避免刺激性食物。4病情观察（1）观察生命体征，尤其注意有无发热征象。（2）观察咳嗽、咳痰、喘息等，注意痰液的颜色、性状、量、气味的变化。5保持呼吸道通畅，遵医嘱给予氧气吸入。6根据医嘱正确收集痰标本。7药物治疗护理：观察抗生素和止咳、祛痰药物的作用及不良反应。8健康指导：指导病人正确咳嗽及有效排痰，劝其戒烟并预防感冒，加强体育锻炼，增强抗病能力，避免劳累。4四、肺炎的护理常规肺炎(pneumonia)是由多种病因引起的肺实质或间质内的急性渗出性炎症。1按呼吸系统疾病病人的一般护理。2休息与体位：急性期绝对卧床休息，胸痛时取患侧卧位，呼吸困难者取半卧位，注意保暖。3饮食护理：高热量、高蛋白、高维生素、易消化饮食，鼓励病人尽量多饮水。4病情观察（1）观察神志、生命体征及尿量的变化，如体温骤降，血压下降，皮肤苍白应及时告知医生并做好抗休克抢救。（2）观察咳嗽、咳痰情况，注意痰液的性质、量、颜色并做好记录。5遵医嘱给予氧气吸入。6药物治疗护理（1）注意观察升压药的效果，根据血压调整输液滴速，防止药物外漏。（2）应用抗生素前应遵医嘱迅速留取痰，血液及其他分泌物送细菌培养和药敏试验。7高热时按高热护理常规。8健康指导：加强体育煅炼，增强抗病能力，避免受凉和过度劳累。5五、支气管哮喘的护理常规支气管哮喘(bronchialasthma)是一种以嗜酸性粒细胞、肥大细胞和T淋巴细胞等多种炎症细胞参与的气道变应性炎症和气道高反应性为特征的疾病，导致易感者发生不同程度的可逆性广泛气道阻塞的症状。1按呼吸系统疾病病人的—般护理。2休息与体位：卧床休息。哮喘发作时取强迫体位，并给予支撑物，使之舒适省力．3饮食护理：发作过程中，不宜进食，缓解后给予营养丰富、易消化饮食。禁食与病人发病有关的食物，如鱼、虾、蟹等。4病情观察：注意观察发作先兆，特别夜间要加强巡视病房，如病人有鼻咽痒、喷嚏，流涕、眼痒等黏膜过敏症状，或胸前压迫感，立即告知医生，以便采取预防措施。注意观察呼吸频率、深浅及节律变化。5遵医嘱给予氧气吸入。6保持呼吸道通畅，及时清除呼吸道痰液、痰栓，必要时做好行气管插管、气管切开的准备，配合抢救。7用药护理：应用拟肾上腺素类药物时，注意有无心悸、兴奋、恶心、呕吐等不良反应，冠心病和高血压病患者忌用此类药物。应用茶碱类药物时，