1例高龄脑梗死合并吸入性肺炎患者目标导向早期活动护理实践

Nursing Practice of Goal-oriented Early Activity in 1 Elderly Patient with Cerebral Infarction Complicated with Aspiration Pneumonia

总结1例高龄脑梗死合并吸入性肺炎患者实施目标导向早期活动的护理实践。本研究选取2020年11月青海省人民医院重症医学科收治的1例脑梗死合并吸入性肺炎高龄患者的病历资料进行回顾性分析。该患者因“脑梗,吸入性肺炎”于2020年11月4日转入重症医学科。入科时患者神志呈朦胧状态,氧饱和度低,口腔气管插管处立即给予呼吸机应用。双肺呼吸音粗并可闻及散在的湿啰音。胸部CT显示:肺部见大片密度增高灶。该患者高龄、肺部感染极重,共两次口腔气管插管,护理难点多。故通过建立由护士主导的目标导向早期活动方案,包括人员组建、方案制定、安全管理、质量控制,对该患者实施个体化目标导向早期活动后护理效果满意,明显改善了患者肌肉健康水平,患者康复出院。

The nursing practice of implementing goal-directed early activities in 1 elderly patient with cerebral infarction com⁃bined with aspiration pneumonia is summarized.The study selected the medical records of a case of elderly patient with cerebral in⁃farction combined with aspiration pneumonia admitted to the hospital in November 2020 for retrospective analysis.The patient was transferred to the Department of Critical Care Medicine on November 4,2020 for“cerebral infarction and aspiration pneumo⁃nia”.At the time of admission,the patient was in a hazy state with low oxygen saturation,and was immediately placed on a venti⁃lator by oral tracheal intubation.Breath sounds in both lungs were coarse and scattered wet rales could be detected.Chest CT showed large foci of increased density seen in the lungs.This patient was of advanced age,had an extremely severe lung infection,and was intubated twice for oral tracheal intubation,which made nursing care difficult.Therefore,through the establishment of a nurse-led goal-oriented early activity program,including personnel formation,program development,safety management,quality control,the nursing effect after the implementation of individualized goal-oriented early activity for this patient was satisfactory,and significantly improved the patient’s muscle health level.And the patient was discharged from the hospital with recovery.