急性左心衰竭 个案共32页文档

急性左心衰个案护理范文一、患者基本情况。

老张，男，65岁，那可是个“老烟枪”，烟龄都有40多年了。

平时呢，就有点高血压，也没太当回事儿。

结果有一天，突然就喘得不行，脸也憋得紫紫的，被家人紧急送到了我们医院。

一检查，好家伙，急性左心衰。

二、护理评估。

# （一）身体状况。

1. 呼吸困难。

老张刚送来的时候，那喘气就像拉风箱似的，大口大口地喘着粗气。

半卧位都不行，非要坐起来，还把床头摇得高高的，整个人就像刚跑完马拉松似的，累得不行。

2. 面色和皮肤。

脸色紫绀，就像被人掐住了脖子一样。

皮肤呢，又湿又冷，感觉就像刚从水里捞出来的一样，可把我们吓坏了。

3. 生命体征。

血压也不听话了，忽高忽低的。

心率呢，快得像打鼓，都快130次/分了。

呼吸频率更是吓人，达到了30 40次/分，感觉他每呼吸一次都用尽了全身的力气。

# （二）心理状况。

1. 焦虑恐惧。

老张躺在病床上，眼睛里满是恐惧。

他一直拉着我的手说：“护士啊，我是不是快不行了？”看得出来，他特别担心自己的病情，毕竟这种突然的重病，换谁都害怕。

三、护理措施。

# （一）一般护理。

1. 体位安置。

我们赶紧把老张安置在一个舒适的体位，让他坐在床边，双腿下垂。

这就像给心脏减轻了负担一样，让他能稍微舒服点。

老张还开玩笑说：“这个姿势像个大虾米，不过还真感觉喘得没那么厉害了。

”2. 休息与活动。

告诉老张现在得好好休息，啥事儿都别想。

在病情稳定之前，活动范围就只能在床上了。

老张开始还不乐意，说自己闲不住，我们就耐心地给他解释：“张大爷，您现在就像一辆破了胎的汽车，得先把胎补好才能跑啊。

”3. 饮食护理。

饮食上可不能马虎。

给他安排了低盐、低脂、易消化的食物。

老张开始还抱怨说没味道，我们就跟他说：“大爷，您现在身体里的‘小河流’（血液循环）都堵住了，盐吃多了就更堵了，等病好了，您再吃点好的。

”# （二）病情观察。

1. 生命体征监测。

我们就像老张的小跟班一样，密切观察着他的生命体征。

一例急性左心衰患者的护理一、病情介绍患者钱某，女，79岁，诊断：急性左心衰。

患者由于“突发心悸、气促1小时。

”自觉症状加重，伴心悸，面色苍白，出大汗，于2015年5月15日16：50由家人呼叫我院120车接回抢救室，体查：患者神志清，面色苍白，烦躁不安，大汗淋漓，皮肤湿冷，鼻翼煽动，口唇发绀，颈软，颈静脉充盈，双肺呼吸音粗，两肺可闻及散在干、湿罗音，心尖听诊呈奔马律，有少许咳嗽，无咳痰，脉搏：122次/分，呼吸：35次/分，血压：178/101mmHg，端坐卧位，SPO2：56%。

既往有高血压，糖尿病病史。

入院后即于端坐卧位，高流量鼻导管吸氧（6L/分），持续心电监护、遵医嘱予单硝酸异山梨酯针10ml+0.9%NS100静脉微量泵入扩张冠状动脉、降压，并抽血常规、电解质、肾功六项、凝血四项等送检，患者气促症状缓解不明显，血压仍高，改予0.9%NS250+硝酸甘油40mg静脉滴注，20ml/h静脉微量泵入，予吗啡10mg+0.9%NS10ml静脉推注，予呋塞米20mg静脉推注，当血压降至140/80mmHg，予西地兰0.2mg+0.9%NS20ml缓慢推注，改予单硝酸异山梨酯针组液静滴扩冠、降压，同时再建立另一条静脉输液输注0.9%NS250+氨茶碱0.25g+地米10mg溶液进行平喘，约18:30症状逐渐缓解，在医护人员陪同下于车床送入ICU进一步治疗。

二、护理过程1.心输出量减少1.1评估患者神志清，面色苍白，烦躁不安，大汗淋漓，皮肤湿冷，口唇发绀，脉搏：122次/分。

1.2目标与计划患者经抢救后唇甲转红，皮肤温度回暖，每小时尿量大于40ml。

1.3措施（1）遵医嘱予单硝酸异山梨酯针10ml+0.9%NS100ml以30ml/h静脉微量泵入扩张冠状动脉降压，并抽血常规、电解质、肾功六项、凝血四项等送检。

静滴10分钟后，患者气促症状缓解不明显，血压:175/100mmHg，R:34次/分，改予0.9%NS250+硝酸甘油40mg静脉滴注，20ml/h静脉微量泵入扩张小静脉及冠脉血管，降低心脏供氧，首次剂量10mgiv缓推，5分钟后测量一次血压，后渐行原嘱，每15—30分钟复测血压，并予吗啡10mg+10mlNS静脉推注，iv注射10分钟，过程中测心率、呼吸，防止呼吸抑制。

急性左心衰个案护理范文英文回答：Acute left heart failure, also known as acute pulmonary edema, is a medical emergency that requires prompt and effective nursing care. The main goals of nursing care for a patient with acute left heart failure are to improve oxygenation and relieve symptoms, stabilize the patient's condition, and prevent further complications.Firstly, the nurse should closely monitor the patient's vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation. Any changes in these parameters should be promptly reported to the healthcare team. In addition, the nurse should assess the patient's respiratory status, paying attention to the presence of dyspnea, cough, and frothy pink sputum.To improve oxygenation, the nurse should administer supplemental oxygen as prescribed and ensure that thepatient is in an upright position to facilitate lung expansion. The nurse should also encourage deep breathing exercises and provide emotional support to help alleviate anxiety and promote relaxation.To relieve symptoms, the nurse should administer diuretics as prescribed to reduce fluid overload and decrease pulmonary congestion. Close monitoring of urine output is essential to assess the effectiveness of diuretic therapy. In addition, the nurse should administer medications to improve cardiac function, such as vasodilators and inotropic agents, as prescribed by the healthcare team.Stabilizing the patient's condition involves maintaining a stable fluid balance and preventing fluid overload. The nurse should closely monitor the patient's intake and output, as well as daily weights, to assessfluid status. Strict fluid and sodium restrictions may be necessary, and the nurse should educate the patient and family members about the importance of adhering to these restrictions.Preventing further complications is crucial in the management of acute left heart failure. The nurse should closely monitor for signs of worsening heart failure, such as increased dyspnea, orthopnea, or peripheral edema. In addition, the nurse should educate the patient and family members about the importance of medication compliance, regular follow-up appointments, and lifestyle modifications, such as a low-sodium diet and regular exercise.In conclusion, nursing care for a patient with acuteleft heart failure involves closely monitoring vital signs and respiratory status, improving oxygenation, relieving symptoms, stabilizing the patient's condition, and preventing further complications. Prompt and effective nursing interventions are essential in managing thismedical emergency.中文回答：急性左心衰竭，也称为急性肺水肿，是一种需要迅速和有效的护理的医疗急症。

急性左心衰个案护理范文英文回答：Acute left heart failure is a medical emergency that requires prompt and appropriate nursing care. The primary goal of nursing care for a patient with acute left heart failure is to stabilize the patient's condition, relieve symptoms, and prevent complications. Here is a nursing care plan for a patient with acute left heart failure:1. Monitor vital signs: Regularly assess the patient's blood pressure, heart rate, respiratory rate, and oxygen saturation. Any significant changes should be reported immediately.2. Administer oxygen therapy: Provide supplemental oxygen to maintain adequate oxygenation. Monitor thepatient's oxygen saturation levels and adjust the oxygen flow rate as needed.3. Assess respiratory status: Monitor the patient's respiratory effort, breath sounds, and oxygen saturation. Auscultate lung sounds for crackles or wheezes. Administer prescribed bronchodilators or diuretics to relieve pulmonary congestion.4. Monitor fluid balance: Assess the patient's intake and output, including urine output, to evaluate fluid status. Administer diuretics as prescribed to promote diuresis and reduce fluid overload.5. Elevate the head of the bed: Position the patient ina semi-Fowler's position to promote optimal lung expansion and reduce dyspnea.6. Administer medications as prescribed: Administer medications such as vasodilators (e.g., nitroglycerin) or inotropic agents (e.g., dobutamine) to improve cardiac function and reduce preload and afterload.7. Provide emotional support: Assess the patient's emotional status and provide reassurance and support.Encourage the patient to express feelings and concerns.8. Educate the patient and family: Provide education about the condition, including signs and symptoms of worsening heart failure, medication management, andlifestyle modifications such as a low-sodium diet andregular exercise.中文回答：急性左心衰竭是一种需要迅速和适当护理的医疗急症。

急性心力衰竭护理个案范文英文回答：Acute heart failure, also known as congestive heart failure, is a condition in which the heart is unable to pump enough blood to meet the body's needs. It can be caused by various factors such as a heart attack, high blood pressure, or a viral infection.Nursing care for a patient with acute heart failure involves several aspects. Firstly, it is important to monitor the patient's vital signs, including heart rate, blood pressure, and oxygen saturation levels. This helps to assess the severity of the condition and guide further interventions.Fluid management is another crucial aspect of care. Patients with acute heart failure often experience fluid overload, leading to symptoms such as shortness of breath and swelling. It is important to closely monitor thepatient's fluid intake and output, and administer diuretics as prescribed to help remove excess fluid from the body.Oxygen therapy may also be necessary to improve oxygenation and relieve symptoms of respiratory distress. This can be administered through a nasal cannula or a face mask, depending on the patient's needs.In addition to these interventions, it is important to provide emotional support to the patient and their family members. Acute heart failure can be a frightening and stressful experience, and patients may benefit from counseling or support groups to cope with the condition.中文回答：急性心力衰竭，也被称为充血性心力衰竭，是一种心脏无法泵出足够血液以满足身体需求的病症。