Anxious
correlative factor
Environmental changes.
Lack of disease-related knowledge.
Gross.
main performance
Panic, depression, doubt.
Nervous, excitable, difficult to sleep.
Crying and depression alternate, poor appetite.
Nursing goal
Patients can gradually adapt to the environment.
Patients can adjust their mood swings by themselves, and their worries are basically eliminated.
Patients can learn about the health knowledge of the disease, the significance and prognosis of the operation.
Nursing measures
Patiently introduce the ward environment, basic facilities, relevant systems, doctors in charge and nurses in charge to patients.
Keep the ward clean and hygienic, and provide patients with a clean, comfortable, quiet and satisfactory rest environment.
Analyze the main causes and the most likely causes of patients' anxiety, and encourage patients to boldly ask their own inner questions and answer them.
Comfort and considerate patients, talk with patients, try to understand their psychological state, and carry out targeted health education, such as explaining the cause of the disease, the current stage of the disease, the necessity and effect of surgery, etc.
According to the operation mode and specific needs, bedside exercises and guidance are given to the problems that patients may encounter after operation, such as the methods of protecting wounds when coughing, and reducing the tension of local wounds as much as possible when getting out of bed early. We can press the wound from both sides of the abdomen to the middle with both hands to improve the confidence of patients to overcome the disease.
Instruct patients to divert their attention, so as to reduce their psychological burden and nervousness, such as reading books, reading newspapers, listening to light music and talking with roommates.
Critical assessment
Patients' understanding of the causes and consequences of anxiety; Ways to eliminate anxiety, master common sense of disease and health.
The patient's feel and adaptation to that new environment.
Whether the patient actively cooperates with the diagnosis, treatment and nursing work of medical staff.
sleep disorder
correlative factor
Environmental change, nursing operation, lighting, noise and other influences.
Excessive blood loss and secondary anemia.
Anxiety, panic.
main performance
Insomnia or deep sleep at night is easy to wake up.
Tired and sleepy during the day.
Nursing goal
Patients can describe factors that hinder or affect sleep.
Patients learn the skills of inducing sleep and consciously improve the quality of sleep.
The patient's mental condition has improved.
Nursing measures
Reduce or eliminate the factors that cause patients' emotional anxiety and sleep interruption in the environment.
Noise elimination: When the patient sleeps, he can close the door, open the window, close the curtains, provide night lighting, and reduce strong light and noise stimulation.
Avoid external interference: arrange nursing operation reasonably to avoid waking patients unnecessarily; At noon and at night, when the patient is ready to sleep, he refuses to visit.
Provide scientific and comfortable methods to induce sleep.
Provide clean sheets, pajamas, bedding and comfortable pillows.
Tell him to take a conscious and comfortable position and generally avoid lying on the left side.
Read books, listen to light music, relax/take a deep breath training or soak your feet in hot water and massage your back before going to bed.
Drinking a cup of hot milk before going to bed will help you fall asleep and avoid the stimulation of stimulants such as coffee.
Ensure the fixation of various pipelines (such as infusion tubes and catheters) after operation, and observe its curative effect carefully enough.
Critical assessment
Whether the patient's sleep quality has improved.
What is the patient's mental state and whether his attention is focused.
Whether the causes affecting patients' sleep are eliminated, whether the measures to promote patients' sleep are used and how effective they are.
malnutrition
correlative factor
Excessive vaginal bleeding leads to secondary anemia.
Lack of nutrition knowledge and insufficient intake.
Emotional fluctuations affect appetite.
main performance
Pale face, dizziness and fatigue.
Nausea and anorexia.
Mental fatigue.
Nursing goal
Patients can try to increase the types and quantities of nutrients they consume.
Patients can talk about the causes of their malnutrition and improvement measures.
The patient's face turned red, his mental condition improved, and his weight did not drop significantly.
Nursing measures
Introduce the importance of getting enough nutrition to patients.
Guide or provide patients with adequate nutritious food and create a good dining environment.
Provide a pleasant and comfortable dining environment (no toilets, no garbage, etc.). ) and create a fresh and beautiful environment (such as flowers on the table).
Provide a variety of nutritious and digestible foods suitable for patients' tastes, such as eggs, lean meat, animal liver, dairy products, spinach, fungus, red dates and so on.
In addition to ensuring high protein, high vitamin and iron-rich nutrition, food should also pay attention to the reasonable collocation of animal protein and plant protein, meat dishes and vegetarian dishes, and taste dishes.
Hemoglobin, serum protein, plasma transferrin and lymphocyte count were monitored regularly to observe the therapeutic effect.
According to the test data, timely treatment. Those with frequent dizziness and severe anemia should stay in bed when bleeding, ensure sleep, avoid overwork and strenuous exercise, reduce physical exertion, transfuse blood many times when necessary, correct anemia in time and operate as soon as possible.
Critical assessment
Whether and to what extent the patient's complexion and hemoglobin have improved.
Whether the patient can tolerate the operation and how the wound heals after operation.
Regularly monitor the relevant laboratory data and analyze the treatment effect.
There is a risk of infection.
correlative factor
Excessive blood loss, weak constitution.
Poor tolerance, decreased activity and decreased physical resistance.
Postoperative indwelling catheter.
main performance
Tired and weak, easy to catch a cold.
Abdominal pain, more common in pelvic inflammatory disease.
Frequent urination, urgency, dysuria, pruritus and swelling of vulva are more common in urethritis and vulvar inflammation.
Nursing goal
The patient had no pelvic, genital, vulvar or urinary tract infection.
The patient has no symptoms of upper respiratory tract infection.
Nursing measures
Preoperative:
The temperature, pulse and respiration were measured at 3: 00 pm and 7: 00 pm the day before operation and in the morning of operation, 65438 0 times. If the body temperature exceeds 38oC, report to the doctor in time to decide whether to operate; The body temperature should be measured four times a day after operation. If you have fever, you should increase the frequency of temperature measurement and monitor the blood picture.
Prepare the skin 1 day before operation, be careful not to injure the skin by accident, and do a good job in general hygiene.
Wash vagina with 0. 1% bromogeramine 1 every day for 3 days before operation, and insert 0.4g metronidazole into vagina.
Soap water enema 1 time was given in the evening before operation to clean the intestine.
Catheter was placed in the morning of operation.
Eat semi-liquid diet 2 days before operation, change to liquid diet 1 day before operation, and eat after dinner before operation.
Use antibiotics according to doctor's advice during perioperative period.
Pay attention to keep warm to prevent colds.
postoperative
After general anesthesia, take off the pillow, lie flat and tilt your head to one side until the patient is fully awake to prevent aspiration pneumonia.
After 24 hours, the condition is stable, so it is advisable to take a semi-sitting and lying position to reduce the wound tension and facilitate local drainage.
Keep the catheter unobstructed and pay attention to the change of urine color, quantity and character. Prevent catheter blockage and avoid repeated intubation operation.
Keep the vulva clean and sanitary, and wipe the perineum with 0. 1% bromogeramine cotton ball every day 1 time until the catheter is removed.
Indwelling catheter and drainage bag, change 1 time a day.
Critical assessment
Changes of patient's temperature and white blood cell count.
Does the patient have signs of secondary infection, and are preventive measures effective?
The patient's vaginal secretion has no peculiar smell and abnormal secretion.
Wound pain
correlative factor
The anesthetic effect disappeared after the operation.
The patient's tolerance has decreased.
main performance
Complain about the pain in the wound.
Painful face, groaning.
Pulse, rapid breathing, sweating.
Nursing goal
The patient complained that the wound pain was relieved or disappeared.
The patient rested quietly.
Nursing measures
Explain the cause and possible duration of wound pain to patients in time, so that patients can be psychologically prepared.
Pay attention to the nature and degree of wound pain.
Strengthen psychological comfort and try to distract patients' attention.
Encourage patients to overcome pain with perseverance, and use sedatives and analgesics according to doctor's advice when necessary.
Warn patients that painkillers should not be used more, so as not to affect the recovery of gastrointestinal function after operation, and have drug resistance and addictive side effects.
Help patients to use ear pressure therapy to relieve pain.
Critical assessment
The degree and duration of the patient's wound pain.
The effect of using drugs to relieve pain.
How does psychotherapy assist wound pain?
There is the possibility of bleeding after operation.
correlative factor
Vascular surgery injury, ligature slippage.
Increased vascular fragility.
main performance
The patient was pale and emotional.
Blood pressure drops, pulse speeds up, and limbs get cold.
The wound oozed blood and the dressing was soaked.
Vaginal bleeding and moist skin.
Nursing goal
The patient's wound was not bleeding, and the dressing was dry.
No bleeding or hemostasis in vagina.
The patient's vital signs are stable.
Nursing measures
Closely observe the changes of blood pressure, pulse and respiration, and measure 1 time every 30-60 minutes, and 1-2 times a day after stabilization.
Pay attention to the changes of patient's complexion, consciousness and expression.
Observe the patient's limb temperature and peripheral circulation.
Observe vaginal bleeding. If there is too much bleeding, immediately notify the doctor for first aid.
Observe the bleeding at the wound dressing. If there is much bleeding, inform the doctor in time to find out the reason and change the medicine in time.
Cross-matching blood for standby.
Use hemostatic drugs intravenously according to the doctor's advice, and replenish blood volume, water and electrolyte in time to prevent and treat shock.
Critical assessment
Monitor the changes of patients' vital signs.
Whether the wound has oozing blood and the amount of vaginal bleeding.
Monitor for internal bleeding.
Abdominal distension and abdominal pain
correlative factor
Surgical traction.
Post-anesthesia reaction.
main performance
The patient complained of abdominal distension and pain.
The patient is restless, fidgety and upset.
The anus is stuffy.
Nursing goal
The patient vented anus within 3 days after operation.
Abdominal distension and abdominal pain were relieved.
Nursing measures
Six hours after operation, the patient was instructed to turn over in bed and move his limbs properly.
Drink a small amount of orange water many times to relieve flatulence.
Avoid drinking milk before anal exhaust, so as not to aggravate abdominal distension.
24 hours after operation, patients were encouraged to get out of bed early and exercise slightly to prevent complications such as intestinal adhesion.
Critical assessment
Does the patient know the causes and countermeasures of abdominal distension and abdominal pain?
Whether the time and duration of abdominal distension and abdominal pain have been shortened or alleviated.