IU DNG C BNBI 1: VAI TR CHC NNG IU DNG A-KHI NIM:

X hi mi ngi k vng, lin quan s mong mun ca mi ngi v thi v hnh ng. D c 3 vai tr: 1-VAI TR THC HNH: - p ng nhu cu c bn ca BN - C k nng tay ngh thnh tho - Giao tip tt vi BN - C trch nhm chm sc t/d bnh - Phng bnh v nng cao sc khe cho d trong cng ng 2-VAI TR LNH O V QUN L Hng dn , t chc cho ng nghip,BN, thn nhn thc hin C k hach , theo di v to u kin thun li cho mi ngi t c mc tiu Qun l con ngi ti sn vt t Qun l bo qun dng c,s sch hnh chinh

3-VAI TR NGHIN CU Thc hnh da trn chng c Pht trin ngh nghip Thay i thc hnh chm sc Lun hc hi trau di kinh nghim Ging dy

B-CHC NNG CA IU DNG - Chc nng c lp - Chc nng phi hp Chc nng ph thucTrang 1

BI 2: O C IU DNG A- PHM CHT C NHN IU DNG 1- Phm cht v o c -

Trch nhim cao Trung thc n cn , cm thng Mm mng c nguyn tc Khn trng , t tin Yu ngh

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2-Phm cht m hc - Tc phong nghim tc Sch s , khng mi hi Khng gy tm l cch bit To khng kh gip n nh tinh thn BN

3-Phm cht tr tu - C kh nng quan st nh gi BN C k nng thnh thoTrang 2

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Nghin cu v ci tin Khn ngoan trong cng tc

B- NGHA V NGH NGHIP 1- i vi BN Khng t chi gip Tn tnh trong chm sc Tn trng BN H tr tinh thn

2- i vi ngh nghip -

Lun hc hi nng cao trnh chuyn mn Rn luyn sc khe Trch nhm khi nhn hoc phn cng cng vic Chun mc o c An ton khi chm sc BN

3- Pht trin ngh nghip-

Chun mc trong thc hnh chm sc Ngh nghip da trn chng c Quan h t chc ngh nghip

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4- D vi ng nghip-

Gip , on kt Tn trng Ph bnh c thin ch Truyn th kinh nghim BI 3: NHU CU C BN CA CON NGUI A- 14 NHU CU C BN THEO VIRGINIA HENDERSON 1. p ng nhu cu v h hp 2. Gip BN v n ung v dinh dngTrang 3

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3. Gip BN trong s bi tit 4. Gip BN v t th vn ng, tp luyn 5. p ng nhu cu v ng v ngh ngi 6. Gip BN mc v thay qun o7. Gip BN duy tr than nhit

8. Gip BN v sinh c nhn hng ngy 9. Gip BN trnh uc nguy him khi nm vin 10. Gip BN trong s giao tip 11. Gi BN thai mi v tinh thn, t do tn ngng12. Gip BN lao ng , lm mt vic g trnh mc cm l ngi v dng

13. Gip BN trong cc hat ng vui chi gii tr 14. Gip BN c kin thc v y hc

B- 5 NHU CU CA MASLOW1- Nhu cu v s hon thin

2- Nhu cu v s knh trng , t trng 3- Nhu c c u thng4- Nhu cu an ton , an ninh

5- Nhu cu v th cht , sinh l

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BI 4: V KHUN TIT KHUNA-

V KHUN NI KHOA:

1- NH NGHA: L cc bin fp gim thiu s lng VSV hin c trn 1 vt hay 1

vng no 2- MC CH:

Gm s ly truyn trc tip hay gin tip of VSV t ngi ny sang ngi khc, t vng ny sang vng khc

Gim s vi khun gy bnh, tng an tan cho mi trng sng of con ngi

To cho c th sc khng cao

3- CC TRNG HP P DNG:

Ra tay Cung cp phng tin, vt cha cc dch tit, cht thi (m nht, nc tiu, phn)

Khi ho, ht hi trnh nc bt bn ra ngai Khng cho BN dng chung cc vt dng c nhn: khn lau, bn tiu

Trnh tung bi khi qut dn Lau sch sn nh v tng t vt sch xa cc vt bn Phng bnh fi thang, khng kh vn chuyn c p dng bin php cch ly cho BN nhimB- V KHUN NGAI KHOA:1-

NH NGHA:

L tnh trng nhng vng, vt hon ton khng c s hin din of vi khun, k c bo tTrang 5

V KHUN NGAI KHOA C P DNG TRONG CC TH THUT:2

Xuyn qua da( tim, chc d.) hoc tip xc vi cc vng nim mc v khun(thng tiu) , tip xc vi cc vng da, nim mc khng cn nguyn vn ( nh vt thng, phu thut, sinh ) CC BIN PHP P DNG:

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Dng kim v khun hay mang gng v khun tip xc vi cc vt VK

Khng chong tay qua vng VK Khng c ni chuyn, ho, ht hi vo vng VK

Khi i ngang qua vng VK, khng c quay v hng VK Vt VK b t c xem nh khng cn VK Cc bin php p dng VK ngai khoa Bnh kim tip liu VK fi c gi kh ro (khng ngm dung dch) M gi VK fi xa thn ngi, khng chm vo qun o Phn di tht lng khng c xem l VK Khi mang vt ra khi hp hay gi VK khng c t tr li

Nu nghi ng tnh trng VK of mt vt fi xem vt khng VK BI 5: DU SINH HIU 1- YU CU KHI LY DU SINH HIU:-

D c trch nhim theo di DSH Bit ch s DSH bnh thng , cc yu t nh hng n DSH Phn tch kt qa c nhng quyt nh can thip hp l La chn dng c dng o m ph hp vi BN Bit v tin s, bnh s, hng iu tr, ch nh dng thuc, nht l nhng can thip no nh hng n DSH Bit c cc yu t mi trng lm nh hng n DSH Ty theo tnh trng bnh,D cn t/d nhiu ln hn d khng c kin ca BSTrang 6

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D c th hi vi cc D khc trong tua trc khi thy kt qa DSH bt thng i vi BN ngoi tr DSH c o trc khi thc hin vic thm khm

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2- NH HNG CA ST I VI C TH:-

Tun hon : mch mu ngai bin dn, nhp tim tng ,tng vn mch, mt mi H hp: nhp th tng Tiu ha : chn n , bun nn ,nn ,tiu chy hoc to bn Bi tit: mt nhiu m hi, tiu t , nc tiu c c sm mu Thn kinh: gy nhc u, d kch ng, cu gt, st cao c th dn n m sng, co git nht l tr em

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3- NGUYN TC IM MCH: -

m trong 30 giy khi mch u m trn 1 pht nu mch khng u hoc ngi c bnh l tim mch T/d mch trc v sau khi dng thuc c nh hng n tim mch Cn cho BN ngh nghi t nht 15 pht trc khi m mch Dng 2-3 ngn tay m mch Khng dng ngn ci m Khi thy mch khng u hay bt thng kh m nn m mm tim Khi m phi ch c 4 y t: tn s, nhp iu, cng v sc cng of mch

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4- NGUYN TC M NHP TH: -

Cho BN ngh nghi 15 pht trc khi m Khng bo cho BN bit khi m nhp th Quan st bng hay ngc: khi nng ln h xung m 1 nhp m trn 1 pht nht l nhng ngi c bnh l v h hp Khi m phi ch c 4 yu t: tn s, nhp iu, bin v m sc

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5- NHNG IM CN LU KHI O HUYT P: -

Cho BN ngh nghi 15 pht trc khi o HA Nu BN c dng c f ch 30 sau mi o To tm l , t th thoi mi , chun b v tr thch hp trc khi o HA My o fi f hp vi chi o: chiu di of ti hi = 80-100% hoc chiu rng =40-50% chu vi o chi o ngang vi mc tim khi o HA Si dy dn kh of ca my o fi nm dc theo ng i of ng mch Khng qun o sit chc chi o Thc hin ng k thut o trnh sai s Khng bm hi nhi khi khng ghi nhn c kt qa Khi o HA nn o ng gi, cng my, cng t th, cng v tr nht l trong trng hp cn t/d HA Nu nghi ngh kt qa 5 pht sau o li Nu khng c ng nghe c th dng tay bt mch. T/ hp ny ch o c HA ti a

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BI 6: DINH DNG TRONG IU TR A- MC CH: p ng nhu cu dinh dng hng ngy C tc dng trc tip n nguyn nhn gy bnh Tng cng sc khng cho c th iu ha thn kinh v th dch Phng nga bnh

B- NGUYN TC:-

Ch n iu tr khng ko di T l P: L: G: thay i ty theo bnh l Ch bin thc n ng theo yu cu iu trTrang 9

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Thc n hp khu v, an tan thc fm S dng thc fm c sn, theo ma ng vin, khuyn khch BN hp tc

C- CC PHNG PHP H TR DINH DNG: 1- QUA NG MING: u im:

Theo sinh l d chp nhn n gin , thc hin c mi ni Hiu qa ,t tai bin R tin Nhc im:

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Cn s hp tc ca BN Ph thuc vo cm quang of thc fm Kh tnh ton lng thc fm c tiu th - d thiu Nguy c sc ngi bnh nng Cch H Tr:

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Chia nhiu ba n trong ngy n dm thm vo gia cc ba chnh Dng thc n cao nng lng ung thay nc: sa dinh dng H tr thm cc fng fp nui n khc : truyn tnh mch, n qua ng thng2- NUI DNG QUA SOND D DY:

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U IM:

Sinh l hn nui qua tnh mch Duy tr hat ng ng tiu ha t bin chng hn nui qua tnh mch Gi thnh thp hn nui qua tnh mch t f thuc vo s cng tc of BN so vi n qua mingTrang 10

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NHC IM:

Nhiu bin chng hn nui n qua ming Ph thuc cc phng tin, hoc thc fm cn thit Nui ko di kh tn km Nguy c gim fn x nut of BN Tng gnh nng cho D CCH H TR:

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Cho n qua ng thng khi BN n < lng thc n theo nhu cu C cc lai ng : mi ,ming, d dy mi ,ming ,t trng, hng trng m d dy ra da Phi hp nui qua tnh mch -

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NHNG IM CN LU TRONG KT CHO N QUA NG THNG

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ng c c qua mi nhng c th t qua mng nu mi b vim t ng ng v tr, kim tra trc mi ln cho n u BN cao hn d dy 30 , lu 30 pht sau khi n S lng thc n trung bnh cho ngi ln 1500-3000 kcalo/ngy, 250-300ml/ln, nu cho nhiu hn c th dng nh git ln tc S ln : > 5-6 ln/ngy Tc bm , nh git thc n ty thuc vo tui , tnh trng bnh Cho n vi p lc nh (phu cch d dy 15-30cm) t/gian mi ln cho n khng qa 10 Nu cho n lin tc t/gian nh git 1 chai thc n # 3h Ti cho n fi thay sau 24h Lai thc fm f hp : khng lactose, giu cht x, thnh fn f hp vi tnh trng bnh Nhit thc n # 37- 40 c Kim tra dch tn lu trc khi cho n (>100ml bo BS) Trng ng = NaCl 0,9 %, Oresol, nc chinTrang 11

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V sinh mi ming hng ngy Khi thay ng fi i bn mi Trnh cc nguyn nhn gy tro ngc Gi cho h thng nui n qua ming c sch s, trnh nhim trng 3- NUI N QUA NG TNH MCH: U IM:

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Cung cp dinh dng khi ng tiu ha khng hat ng cn ngh H tr cc phng fp nui n khc NHC IM:

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Khng sinh l Nhiu bin chng Teo nhung mao rut , gim h min dch rut Phc tp v k thut Gi thnh cao

BI 7: CHM SC NGA LET A: CC YU T NGUY C LM TNG TNH TRNG LOT T 1- p lc:-

p lc tng nhng vng xng nh ra p lc cng ln loet cng tin trin Bo ph Nm lu Hn ch vn ng

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2- Tnh trng tri gic: L m , hn m S dng thuc hng tm thnTrang 12

3- S m t: Tiu khng t ch Drap ging, qun o m t m hi V sinh c nhn km

4- S c xt , try xt Drap ging nhn nheo Vt try xt da

5- S dinh dng v chuyn ha Suy dinh dng Ri lan chuyn ha

B CHM SC NGA LET:1- Trnh cn:

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Dng nm cao 20 cm , nm nc ,nm p lc Dng gi chm nhng vng b cn Ko drap ging thng trnh cc np gp Xoay tr BN mi 2h 1 ln 2- Gi da sch s kh ro, trnh tn thng

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Thay qun o drap ging khi m t do tiu tiu khng t ch, m hi nhiu , hoc do dch tit t cc vt thng, v tr dn lu V sinh da hng ngy : tm BN Qun l cht tit: dch t vt thng , ni dn lu thay bng khi thm t dch , ti dn lu c x mi 8h hoc sm hn nu dch y 2/3 ti , kim sat cc ch ni of h thng dn lu , nc tu phn : dng cc dng c qun l nh t giy, tm lt Ct ngn mng tay nga lm try da do co gi 3- Kch thch tng tun han ti ch:Trang 13

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Massege vng da b cn Tp vn ng ch ng hay th ng Dng sc nng : n chiu , nh nng mt tri lm tng tun han ti ch4- Nng cao tng trng

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Dinh dng : cung cp y cht dinh dng c bit l cht m B sung: vit C tng sc khng , vit A , Zn gip vt thng mau lnh5- Qun l nhim khun:

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H hp : vim phi Tit niu : nhim trng tiu Tiu ha :RLTH Sinh dc

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BI 8: CHM SC VT THNG A- NGUYN TC THAY BNG VT THNG: -

p dng k thut VK tuyt i khi thay bng Mi mm thay bng ch dng ring cho 1 BN Ra vt thng ng nguyn tc t trong ra ngai Mt BN c nhiu vt thng th u tin : VT v khun- VT sch-VT nhim Ra vng da xung quanh vt thng rng ra ngai 3-5 cm Bng bng p ln VT fi ph kn v cch ra VT t nht 3-5 cm VT c tc, lng, phi co sch trc khi thay bng Mt s lai VT c bit khi thay bng fi c y lnh iu tr nh VT ghp daTrang 15

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/ vi nhng BN au nhiu khi thay bng c th bo BS cho thuc gim au 20 pht trc khi thay bng Nu cn cy m tm vi khun cn fi ly bt m ni VT trc ri que gn VK pht ln vng y hoc thnh bn ca VT Dng kim VK hoc mang gng VK khi ra VT Thi gian bc l VT cng ngn cng tt

B- CC YU T LM LNH VT THNG: -

VT fi kh sch, thay bng khi thm t dch B mp VT cng gn st nhau th cng mau lnh Cng gim bt nguy c xm nhp of VK vo VT gip VT mau lnh Dinh dng y u n cung cp cht m Dng cc cht kch thch m ht nh cc cht c tinh ch t du m u, mt ong, nhau thai Thay bng nh nhng, khng c ch xt mnh s tn thng m ht Dung dch ra VT fi ph hp vi tnh trng VT BN b au do thay bng VT lm cho tun han VT km VT lu lnh Tng tun han ti ch, trnh p ln VT nht l nhng VT v tr d cn nh vng mng

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C- PHN LAI VT THNG: 1- VT v khun: do phu thut vin gy ra 2- VT sch: VT c t cht tit nh try xt, rch da, khng c m hai t3- VT nhim: c cc du hiu nhim trng, c nhiu cht tit v c bit c

s hin din of cc m hai t D- CC YU T NH HNG N S LNH VT THNG 1- TUI: Ty theo la tui m tin trnh lnh VT khc nhau,tr em VT mau lnh hn ngi ln, ngi gi, ph n mang thai c VT lu lnh hn

2- TNH TRNG OXI TRONG MU: Cc bnh l thiu oxi trong muTrang 16

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Thiu mu Gim th tch tun han

3- DINH DNG:-

Th trng BN: gy qa hay bo ph cng lm nh hnh n qa trnh lnh VT Ch n c y cht dinh ng hay khng? Giu cht m khng? Vitamine: A, B, C, D, E, K

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4- C NHIM TRNG: Vim hng, vim phi, nhim trng tiui km khng? Nu c VT s lau lnh hn5- S P QA MC NI VT: p lc ti ch, ch xt, s va chm... 6- SANG THNG TM L: Stress, au n lm VT lu lnh 7- BNH L KM THEO: Gam tun han ngai bin, tiu ng, tng ur

huyt, suy gim min dch. 8- CC LAI THUC DNG KM THEO: Ha tr, corticoid, gy t ti ch cng u nh n tin trnh lnh VT

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BI 9: NGUYN TC DNG THUC A- YU CU CN THIT KHI DNG THUC:1- YU CU HIU BIT V THUC: D cn phi bit r v thuc trc khi

s dng cho BN, bao gm:-

Tn thuc: tn ha hc, tn bit dc Tc dng chnh, tc dng ph Liu dng Cch s dng c tnh of thuc i vi c quan no Thi gian o thi, thi gian bn hy Tng tc thuc, cng hngTrang 18

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2- YU CU HIU BIT V BN: D Cn phi hiu r BN trc khi a

thuc vo ngi bnh,iu ny s gip ngi iu tr cho thuc chnh xc, s dng thch hp v an ton cho BN-

Tn, tui, s ging Phi, nu l n th xem c thai hay khng Cn nng Chun on bnh Tin s bnh, tin cn d ng vi thuc Tnh trng hin ti, triu chng sn c trn ngi bnh Kh nng dng thuc Kh nng dunh np thuc S tch t thuc, lu i vi BN ln tui T/di xn chc nng cn thit Kin thc v s hiu bit of BN v thuc

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3TC PHONG LM VIC V TRCH NHIM OF D KHI DNG THUC CHO BN -

C TINH THN TRCH NHIM

Sng sut khi nhn y lnh Khi dng bt k 1 lai truc no cho BN, D fi lun kim tra thuc theo ng y lnh t h s hay toa thuc, khng nhn y lnh qua li ni, qua ming hoc qua in thoi Nu nghi ng y lnh fi hi li, khng c t sa i y lnh Khng c fa trn cc loi thuc vi nhau nu khng c y lnh Thnh tht khai bo khi c sai phm Khng t thm ,bt, sa cha, thay i thuc, liu khi dng LM VIC C KHOA HC:

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D cn fi bo qun thuc an ton, gi thuc ni thong mt nhit thch hp ty theo tng loi thuc Sp xp thuc ngn np, theo th t, d ly d tmTrang 19

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Thuc c bng A , B fi c ct gi ng theo qui ch T thuc nn gn ni lm vic Nhn thuc r rng, sch s D fi t/di BN trc, trong v sau khi dng thuc Thuc nc fi ring thuc vin, thuc ung ring thuc bi ngoi da Kim tra thuc mi ngy, bn giao mi ca trc, ghi vo s bo co r rng, b sung c s thuc , bn giao kim tra y sau mi phin trc B- CC TAI BIN KHI DNG THUC 1- DO V KHUN KHNG TT p xe nng Vim tnh mch Nhim trng huyt 2- DO TC DNG CA THUC: Shoch do c th phn ng vi thuc Vim tnh mch do tnh ca thuc 3- DO QA TRNH TIM-

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Nhm ln thuc: khng p dng 3 tra 5 i Gy kim: BN giy gia Chmdy thn kinh, mch mu do xc sai v tr Tn thng m hoi t Shoch do bm thuc qa nhanh Tc mchdo: kh, thuc, vt l (lng) Tim nhm vo ng mch p xe lnh do thuc khng tan

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D-NHNG IM CN LU KHI DNG THUC QUA CC NG: 1- UNG:-

T/dng chm, t gy tai bin, tin dng, khng c ung cc lai thuc cng 1 lc vi nhauTrang 20

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T/di DSH khi dng cc loi thuc c t/d ln h tun hon, h hp Cho BN ngm nc , ht qua ng ht hoc fa thuc vi 1 t ng d ung Thuc ng hoc c mi tanh khng nn ung sau khi n Thuc li tiu fi ung trc 15 gi Thuc lm tn thng nim mc d dy fi ung sau khi n no Thuc c t/d lm hi men rng nn ung qua ng ht Thuc sunfamide cho ung vi nhiu nc trnh gy lng ng thn Nn ung thuc vi nhiu nc tt nht l nc m

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2- TIM THUC: -

Nhn nh c BN v hiu r ti sao dng thuc cho BN Chun b thuc dng cho BN

K/tra thuc: tn thuc, liu lng, ng tim, cht lng, hn s/dng, s n/vn

Chun b kim v bm tim: s lng thuc, m c of thuc, ng tim, kch c BN, loi thuc-

Tnh liu lng thuc chnh xc Thc hin nguyn tc VK khi tim thuc T/hin 3 tra, 5 i, 5 ng trong sut qa trnh tim thuc Chn c kim v chiu di kim thch hp Khng fa trn cc loi thuc vi nhau trong cng 1 ng tim Xc nh v tr tim ng, nn thay i v tr tim Chn vng tim: c th lng khng gng cng Kim khng dnh thuc trc khi tim Khng c m ngp kim khi tim m v rt kim cng 1 gc Khng nn tim lng thuc nhiu qa so vi quy nh Tim thuc chm, khong 10 giy/1 mlTrang 21

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Khi tim heparine khng nn rt kim th mu v c th lm tn thng m di

Khng nn massage vng tim khi tim heparine hoc insulin v c th gy tn thng m v gim hp thu Sau tim dng lc n nh ln vng tim Theo di tnh trng BN trong v sau khi tim T/di v lng gi s p ng thuc of BN Gii thch cho BN hiu v vai tr v tc dng of thuc

Ghi h s: ch ghi nhng loi thuc do chnh tay mnh lm: ngy, gi tim, tn thuc, liu lng, phn ng of BN v tn BS iu tr Gio dc y t cho BN v ch n, sinh hot ty loi thuc dng

3- QUA SONDE D DY: BN hn m cho ung qua sonde d dy Thuc ung qua sonde cn tn nhuyn v pha long Kim tra v tr sonde Bm 15 -30 ml nc (ngi ln) 5 -10 ml (tr em) trc v sau khi bm thuc Nu c 2 3 loi thuc nn bm tng loi, khong cch gia 2 loi l nc trnh tng tc Nu ang dng my ht qua sonde th ngt my ht khong 20 30 pht sau khi bm thuc ri mi hot ng li Ghi r loi, s lng

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BI 10: TIM TRUYN DUNG DCH A- MC CH: 1. Bi hon nc v in gii 2. Thay th tm thi lng mu mt 3. Nui dng ngoi rut cho c th 4. Cho mt s lng ln thuc trc tip vo mu 5. Duy tr nng thuc ko di trong mu 6. Mt s mc ch khc nh gii c, li tiu, gi TM trong trng hp cp cu B- NHNG IU CN LU KHI TIM TRUYN DUNG DCH: Kim tra dch truyn:

Tn dch truyn Hm lng, thuc cn pha theo y lnh Hn s dngTrang 24

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Cht lng dch truyn: mu sc, cn lng S nguyn vn Thc hin 3 tra 5 i 5 ng khi truyn dch cho BN o huyt p trc khi truyn dch cho BN theo di Cho BN i tu, tiu trc khi truyn dch (nu c) Chn TM tim

Nn chn tay khng thun TM ln, t di ng Khng gy cn tr n sinh hat of BN ( trnh ngay khp) Trnh tim li v tr c, TM x, thm nhim -

Khi tin hnh k thut fi ng cch v m bo k thut v khun Tuyt i khng khng kh lt vo TM m bo p lc of dch truyn cao hn p lc mu of BN Kim sot s thng sut of dy truyn, v tr tim, kim iu chnh git ng y lnh Theo di BN 30 60 pht / ln Theo di phn ng chm of BN sau khi dng thuc C th bm thuc qua v tr cao su of b dy truyn Dch truyn khng qa 24 h B dy truyn thay mi 48 -72 h Bng v trng ni thn kim Trnh lu kim qa 24 h i vi kim = kim loi v qa 48 72 h /vi kim lun Dn d BN bo cho D khi

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Cm thy kh chu, kh th, mt, hi hp Ph ni tim, au, dch r r Dch khng chy, dch ht n c chai Khng c t chnh gitTrang 25

C- TAI BIN KHI TIM TRUYN DUNG DCH: 1- DCH THOT RA NGOI: NGUYN NHN:

Lch kim, xuyn kim DU HU V TRIU CHNG:

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Sng ph, da hi ti, lnh, au vng tim, tc dch chy chm X TR:

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Kim tra v tr tim thng xuyn Kha dch truyn ngay khi c du hiu xy ra Tim li v tr khc Hn ch c ng vng chi ang truyn 2- VIM TNH MCH: NGUYN NHN

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Kim, ter gy tn thng mch mu Tnh cht ha hc of dch truyn K thut khng v khun DU HIU V TRIU CHNG:

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au rt vng TM , nng Hi ph nh ni TM c tim X TR:

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Ngng tim truyn ngay Chm nng m ln v tr tim Trnh dng cc TM ln cn Tim li v tr khc 3- THUYN TC MCH:Trang 26

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NGUYN NHN:

Tn thng m do kim hoc ter Do dng khng lu thng to cc mu ng trong lng kim DU HU V TRIU CHNG

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au rt vng TM , nng Hi ph nh ni TM c tim Dch c th khng chy nu cc mu ng lm thuyn tc kim X TR:

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Ngng tim truyn ngay Chm nng ln vng TM b thuyn tc theo y lnh BS Tim li v tr khc Khng c massage ln vng b tn thng 4- QA TI TUN HON: NGUYN NHN:

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S lng ln dch chy qa tun hon DU HIU V TRIU CHNG

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Nhc u, chong vng Mch nhanh, lo s, vt v Kh th n lnh, au lng TM c ni r Tng p lc mu X TR:

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Ngng tim truyn ngay bo ngay du hiu v triu chng cho BS T/di DSH v cc tin trin of shock Duy tr tc dch truyn tht chm 8 git/pht ( gi ven )Trang 27

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5- THUYN TC DO VT L HOC KH: NGUYN NHN:

Cc mu ng b y vo mch mu Kh vo mch mu qua b dy truyn DU HIU V TRIU CHNG:

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Ty theo nguyn nhn m cc du hiu nhi mu 1 vng b thuyn tc..(mch mu phi) X TR:

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Kim tra v tr tim truyn thng xuyn, pht hin sm cc du hiu vim tc TM Khng c cho kh vo mch mu 6- NHIM TRNG: VIM TNH MCH HOC NHIM TRNG HUYT NGUYN NHN:

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K thut tim khng v khun V tr tim chm sc khng ng Dch truyn b khim khun DU HIU V TRIU CHNG

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St , lnh run au, sng vim hoc c dch chy ra ni v tr tim X TR:

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Bo co nhng bt thng xy ra khi truyn dch: au, kh th, st p dng k thut v khun khi tim truyn Che ch thn kim = gc v khun, thay bng mi khi thm t Thay dy truyn mi 48 72 h Dch truyn khng lu qa 24 h Ra tay sch trc khi thc hin cc k thut v khun 7- SHOCK PHN V: NGUYN NHN:Trang 28

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Do c th BN sinh khng th chng li, gy phn ng khng th khng nguyn DU HIU V TRIU CHNG:

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Nhc u, hoa mt, mt, kh th, hi hp, v m hi, tay chn lnh, tnh trng nng c th khng m mch v o HA c X TR:

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Cho BN nm u bng, thng ng th o HA, m mch nu c Bo BS Thc hin nhanh chng cc y lnh v thuc, cho BN th oxy theo y lnh

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BI 11: CHM SC BNH NHN T THNG TIUA-

MC CH V CH NH: -

Gai p: gim p sut ti ch trong trng hp b tiu Chun b BN i phu hoc phu thut h niu Trong phu thut sinh kh Tm vi khun trong nc tiu o p lc bng quang Bnh nng theo di nc tiu 24h: shock, chong do mt nc Chp thn bng quang ngc dng

B-

CHNG CH NH:Trang 30

C-

BN nhim trng l niu o Chn thng dp rch niu o

LU KHI T THNG TIU THNG:

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nh gi tnh trng cng chng of bng quang Gii thch BN an tm hp tc Gi kin o cho BN p dng k thut v khun ngai khoa khi t thng tiu V sinh b phn sinh dc trc v sau khi t thng tiu ng t thng tiu thng l Nelaton La chn ng thng thch hp: ngi ln 16 20 F, tr em 8- 12F Lm trn ng = cht trn tan trong nc K thut t ng phi nh nhng Khng lm gim p sut t ngt trong bng quang gy chy mu Chm sc t/di pht hin nhng tai bin v x tr kp thi T/di s lng, mu sc, tnh cht nc tiu Ghi h s s lng mu sc tnh cht nc tiu Rt thng tiu sm khi khng cn thit BIN CHNG KHI T THNG TIU THNG:

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Nhim trng l tiu, niu o, bng quang, niu qun, thn Tn thng nim mc niu o Xut huyt bng quang ( niu o )D-

LU KHI T THNG TIU LIN TC:

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nh gi tnh trng cng trng of bng quang Gii thch BN an tm hp tc Gi kn o cho BN p dng k thut v khun ngai khoa khi t V sinh b phn sinh dc trc v sau khi tTrang 31

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La chn ng thng ng kch c v ph hp vi BN ( dng Foley) Lm trn ng = cht trn tan trong nc Ch thng khi c ch nh v sau khi p dng nhng bin php c hc khng hiu qa K thut t ng phi nh nhng Khng lm gim p sut t ngt trong bng quang C nh ng thng ng cch: n c nh mt trong i, nam c nh ngc ln bn V sinh b phn hng ngy nga nhim khun ngc dng H thng dn lu nc tiu : gi kh ro nht l ni mng lc, h thng phi kn, thng v mt chiu v khun v thp hn bng quang 60 cm Thay ng mi 5- 7 ngy hoc lu hn ty theo cht liu 2h sau khi rt ng thng tiu mi t tr li Khi khng cn thit theo di nc tiu mi gi ta nn tp cho bng quang hat ng = cch kha ng dn v tho mi 3h mt ln Cho BN ung nhiu nc nu bnh l cho php T/di tnh cht, s lng, mu sc nc tiu Hng dn BN cc du hiu bt thng: au bng di, mu sc nc tiu thay i (c, cn lng, mi hi) s lng nc tiu t, au rt ni l tiu, st, i khi tiu mu th bo ngay X nc tiu mi 8h hoc nc tiu y ti hoc trc khi di chuyn BN Rt ng thng tiu sm khi khng cn ngha trong iu tr GHi h s s lng mu sc tnh cht nc tiu, phn ng of BN nu c BIN CHNG KHI T THNG TIU LIN TC

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Hai t niu o D niu o Hp niu o Si bng quang Teo bng quang Nhim trng huytTrang 32

IU DNG NGOIBI: 1 CHUN B BNH NHN TRC M A- CHUN B BN M CHNG TRNH 1- NGY TRC M: H S:

Cho BN k giy cam kt Kim tra cc xt nghim Kim tra s kt tin phuTrang 33

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NGI BNH:

Ci b t trang BN v bn giao cn thn Tho rng gi, tc gi, chi sch mng tay c sn mu Tc di tht bm hay buc li gn gang Nn cho BN v sinh sch s chiu hm trc m, v sinh, tm ra sch vng m Hng dn BN nhn n ung. Thng nhn n ung 6- 8h trc m M i trng cn chun b ch n k hn trc m 3 ngy Tht tho hoc ung thuc ty x ti hm trc Cho BN gp g ngi nh Trnh BN lo u, cng thng, nn khuyn BN i ng sm, c th thc hin thuc an thn cho BN m trc m 2- SNG HM M: Ly DSH eo bng tn Thay bng li vt thng sch s ( nu c ) Truyn dch, thc hin thuc theo y lnh t sonde d dy ( nu cn) t sonde tiu ( nu cn ) Cho BN thay m D cng thn nhn chuyn BN n phng m

B- CHUN B BN M CP CU: Vic chun b trc m cn s nhanh nhn v thng c chun b trong thi gian qa ngn cng vi tnh trng BN nng cn hi sc, vn tm l BN rt lo lng , do D cn phi c s sp xp v chun b trc m cng chu o th BN trnh c nhiu bin chng sau m. Hi sc tch cc cho BN: Ly DSH, cho BN th oxy, truyn dch, trun mu, gip BS t CVP, thc hin khn cp thuc v cc y lnh khc Khng cho BN n ung Thc hin cc xt nghim c bnTrang 34

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Cng tc tm l trc m vi BN v thn nhn Hon tt th tc h s, bnh n V sinh vng m t sonde d dy, thng tiu Chuyn BN n phng m

Trang 35

BI 2: CHM SC BN SAU M A- CHM SC BN SAU M TI PHNG HI SC: Nu BN gy t ty sng: cho BN nmu = trong 6- 8h sau m, t/di nhc u, cm gic chi v t/ trng vn ng, ch nhit chi ft hin sm tnh trng tc mch 1- H HP: -

T/di st h hp of BN: tn s, tnh cht nhp th Chm sc:

BN m : D cho BN nm u = , mt nghing 1 bn ngn nga dch nn trn vo ng h hp, trnh tt li vo huTrang 36

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Thng ng th cho BN : ht m nht lin tc, nghe phi trc v sau khi ht m Liu php oxy: th oxy qua mi, mask, lng oxy, th my. Bo m cho BN oxy: quanst da nim, qua my, qua xt nghim kh mu T/di du hiu thiu oxy: tm ti, vt v, ch s oxy H/dn BN cch th su Lun gi BN m Theo di:

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Ph n thanh qun do t ni kh qun Lit h hp do thuc gin c, thuc m Hn ch hat ng h hp do au Hat ng of my oxymeter, t/di ch s oxy trn my Da nim Nu nhp th nhanh trn 30 ln/pht hay chm di 15 ln/pht th bo co ngay 2- TUN HON: T/di mch, HA thng xuyn, nn ghi thnh biu d so snh Nn t/di ECG lin tc vi BN nng, BN ln tui, BN c bnh v tim Nu HA gim, mch nhanh c th do thiu nc, mt mu, ri lan nc v in gii, do tai bin gy t ty sng T/di da nim v cc du hiu chy mu qua vt m

3- NHIT :-

BN sau m thng st nh trong 24- 48h u l do p/ng of c th sau m, do mt nc. Sau m 3 ngy m BN vn cn st > 38 C th cn t/di du hiu nhim trng: NT vt m, vim phi, vim ng tiu, nhim trng sau m

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4- THN KINH: Mc m, cm gic, vn ng, ng t. BN c b kch kch ng, vt vTrang 37

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Tnh trng lo s, ht hong khi BN tnh dy trong mi trng l Du hiu t, cm gic hai chi di vi BN gy t ty sng Theo di phn x tnh m

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5- TIT NIU: Tng nc xut nhp mi gi T/di mt nc qua CVP, da nim T/di mu sc, tnh cht, s lng nc tiu T/di cn nng, huyt p Cn chm sc h thng dn lu nc tiu trnh tnh trng nhim trng

6- THEO DI PHN NG CA BN Vt v kch thch -

Do au Do thiu oxy Do duy tr BN 1 t th qa lu Do sonde tiu Run: Do nhit mi trng qa thp Do truyn mu lnh Do thi gian m lu Ngi gi, BN suy dinh dng Do phn ng thuc

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7- THC HIN CC Y LNH V THUC: Thuc v dch truyn thng c s dng qua ng tim. Cn thc hin cc nguyn tc an ton cho BN khi dng thuc v t/di cc tai bin c th xy ra

8- BN C RT NI KH QUN KHI TNH: nh gi du hiu tnh m: c ng mt, tay chn, phn x nut..Trang 38

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Ht m sch trc v sau khi rt ni kh qun Cung cp dng kh v t/di h hp sau khi rt ni kh qun

B- CHM SC BN SAU M TI KHOA NGOI:1-

M BO CHC NNG H HP TI U: Nng cao s gin n phi: ht th su, ho, xoay tr, v lng T/di h hp: nhp th, tn s v nhng bt thng nu c Cho BN ngi dy sm, vn ng, i li ( nu c ) T TH BN SAU M: Khi BN tnh cho nm t th Fowler Chn t th gip BN thoi mi d chu ph hp bnh l THC HIN NGAY V NG CC Y LNH CA THY THUC Gi ng truyn thng, an ton, nn truyn chi trn, trnh tim chi b lit Cn t/di v iu chnh ng s git nht l ngi gi, ngi c bnh l tim mch, suy thn trnh nguy c ph phi cp. T/di DSH trong ngy theo y lnh Thuc tim: thc hin ng gi, ng ng tim, ng thuc CHM SC NG THNG MI D DY: Mc ch: Gip bt cng chng bng sau m,trnh dch trong d dy, gim nn i, t/di chnh xc s lng dch Chm sc:

2-

3-

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4-

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Chm sc rng ming thng xuyn, trnh kh mi ming Ht lin tc hay ngt qung vi p sut 40 cm nc Nn cu ni xung thp gip dch lu thng tt-

Theo di:

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S lng, mu sc, tnh cht dch d dy S lu thng of dch, ng phi ng v tr Theo di tnh trng bng: cng chng, au, nhu ng rut Nu c nhu ng rut bo BS rt sm hay rt theo y lnhTrang 39

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5-

GIM AU V NHNG KH CHU CA BNH NHN:1- GIM AU: Thng mc au ty thuc vo nhiu yu tnh: tm l

sinh l, gii phu, chn thng, trnh vn ha dn tc Lng gi mc au = thang im au Nn gip BN gim au = tm l liu php, nu cn thit c th thc hin thuc gim au hay thuc ng cho BN, nht l nhng BN m ngc, bng, ct sng 2- GIM VT V:-

Nguyn nhn do au, t th, thiu oxy X tr: thc hin thuc gim au, thay i t th thch hp 3- GIM NN: Nn cho BN nm nghing trnh cht nn trn vo kh qun ng thi gip cht nn thot ra d dng

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Thc hin thuc gim nn Theo di s lng, mu sc tnh cht nn 4- GIM CNG CHNG BNG

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t sonde rectal Ht dch d dy Xoay tr, i li sm Cho BN nm t th Fowler, ht th su Theo di du hiu kh th T/di tnh trng bng: nhu ng rut, au, chng 5- GIM NC:

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Nhn th trong khi ung ngm nc Thc hin thuc gim nc theo y lnh 6- AN TON CHO BN:

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Cho thanh ging ln cao, c nh tt cho BN, trnh BN vt v lm st ng dn lu, dch truyn, t 7- THEO DI DN LUTrang 40

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Cho BN nm nghing v pha c dn lu gip dch thot ra ngoi d dng Dn lu nn cu ni xung chai v khun thp hn mt ging T/di s lng, mu sc ,tnh cht dch chy ra 8- DUY TR S TI MU CHO M:

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Triu chng gim ti mu cho m: HA gim, mch 100 ln/pht, vt v nc tiu di 30 ml/pht Du hiu mt cn = in gii: t, mt, nn, kch thch Du hiu gim lng mu: HA gim, nhp tim nhanh, CVP< 4cm nc Du hiu tng lng mu: HA tng, CVP> 15cm nc, ran t y phi, ting nga phi Thc hin b nc v in gii cho BN, truyn mu T/di du hiu mt nc: Nn cho BN ung t nc (nu c) gip BN bt kh mi 9- CHM SC VT M:

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Vt m v khun: th khng thay bng, sau 7 ngy ct ch, nhng nu BN gi hay tnh trng BN suy kit nhiu th nn ct ch chm hn khong 10 ngy sau m Khu tha hay khu h da: y l trng hp gii phu c nguy c nhim trng nn phu thut vin thng h da gip thot dch do D phi chm sc vt m mi ngy hay khi thm t dch, bo co tnh trng vt thng Ch thp: nn thay bng khi thm dch, ct ch sau 14 20 ngy Vt m chy mu: nu t th bng p vt m, nu chy mu nhiu nn bng p tm thi, t/di DSH ng thi bo BS khu li vt m Vt m nhim trng: Nu sau 3 ngy BN c du hu nhim trng vt m th D m bng quan st v ct ch nn m vt m, ra sch v bng li, ghi h s v bo BS, thc hin y lnh khng sinh 10-DUY TR THN NHIT BNH THNG:

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D gi m BN trnh nhim lnh, vim phi T/di nhit BN pht hin nhim trng sau m 11-M BO DINH DNG CHO BN:Trang 41

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Nhng ngy u cha c nhu ng BN thng c nui dng = dch tryn Nhng ngy sau c nhu ng rut th nn khuyn khch BN n = ng ming l tt nht v gip kch thch dch tiu ha, trnh vim tuyn nc bt Cho BN n y cht dinh dng v ph hp tnh trng bnh l Ngoi ra nu khng n c qua ng ming cn nhiu cch nui dng khc m d dy ra da, qua Levin 12-PHC HI CHC NNG TIU CHO BN:

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Nu c thng tiu nn rt sm nu tnh trng BN n nh C gng cho BN i tiu khng cn thng tiu, cho BN ung nhiu nc, vn ng sm Ghi y s lng mu sc tnh cht nc tiu vo h s Chm sc b phn sinh dc v h thng thng tiu trnh nhim trng 13-PHC HI CHC NNG I TIN:

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Sau m khi BN cha n c, do BN tht tho trc m, khng n ung trc m, phu thut c thao tc trn rut cho nn sau m BN khng i cu Sau khi n c: Nu BN bn, D khuyn khch BN vn ng xoay tr v i li sm, n thc n nhun trng, ung nhiu nc Nu BN tiu chy sau m: c th do BN s dng khng sinh, D nn khuyn BN n sa chua, thc hin thuc, t/di mt nc, tnh cht, s lng phn V sinh trong n ung, trnh tiu chy do thc n khng hp v sinh 14-PHC HI CHC NNG VN NG:

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Trnh vim phi, lot, vim tc tnh mch, tc rut Xoay tr BN, gip BN i li sm Tp luyn th ng trn ging, ho, ht th su, v lng Gip BN gim lo u, tm l thoi mi cho BN: cung cp kin thc thng tin v bnh, gio dc BN tham gia t chm sc

Trang 42

BI 3: CHM SC PHNG NGA BN CHY MU SAU M U X TIN LIT TUYN Theo di xut huyt v phng nga xut huyt Ra bang quang:Trang 43

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D chun b dung dch ra NaCl 9%o 10 20 lt ra ngay khi BN n phng hi sc N/tc ra cho chy vo ng dn lu niu o v ra qua dn lu bng quang ra Chai hng thp hn mt ging 60 cm cho chy p lc nhanh trnh lm nght ng do mu ng trong tnh trng chy mu T/di nght ng T/ di s xut huyt: nc mu ln mu cc, Hct gim, mch tng, HA gim, da nim nht, triu chng mc rn gia tng T/di s lng nc vo v ra qua dn lu

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Thng cm mu sau m phu thjut vin thng bm bong Foley 30cc, ko cng ng v ct n trn ng ngay l so chn bong vo c bng quang. Sau 4h th tho n ra. Sau tho n cn theo di st du hiu chy mu

Thi gian ny BN c cm gic mc rn do bong chn vo c bng . Nu BN bt chy mu th h p lc bong bng of ng Foley v gim ko cng chn ng Foley nhng phi theo di st du hiu chy mu

Triu chng mc rn: nn trnh t nhit hu mn, t sonde hu mn v gii thch gip BN hiu. Triu chng mc rn nu gia tng thng l nguy c ang chy mu

Thc hin thuc gim au theo y lnh Vn ng: cho BN nm yn trong thi gian theo di chy mu

Trang 44

BI 4: CHM SC H THNG DN LU MNG PHI TRN BN C T DN LU MNG PHI Gi ng thng, khng nm ln ng dn lu Lun gi im ni kn v cht gia dn lu dy cu bnh cha Gi mc nc trong bnh kn ngp ng thy tinh di t 2-3 cm t 1 ming bng bn bn ngoi chai dn lu v ghi ch thi gian, mc dch Nn c bng theo di ghi thi gian, ngy, gi Bt k s thay i no v tnh cht mu sc, s lng nn ghi vo h s T/di h hp thng xuyn, t/di du hiu kh th:

30 pht trong 2h u sau khi t dn lu mng phi Mi gi trong 24h Mi 2h v sau mi 8h Quan st bt kh trong bnh v mc nc ln xung trong ng thy tinh hay dn lu mng phi. Nu khng thy mc nc ln xung ng thy tinh th:

Quan st nu BN kh th tm ti th h thng b tt Nu BN vn th tt th c th phi gin n tt nn theo di st h hp v bo BS-

Kim tra s si bt trong bnh kn: Bnh thng th si bt ngt qung. Khi si bt lin tc th D xc nh li xem bnh cn kn khng.ng thi nn kp ng li tm im h r of h thng dn lu. Bng li cc im ni, bng li im r khi thay h thng mi Bnh hng lun thp hn dn lu 60 cmTrang 45

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t bnh hng ni an ton, kim tra v tr chai, nu chai lt nho hay nc th kp ng li v thay chai khc ngay Kp ng dn lu li trc khi di chuyn hay thay bnh Khi b tut ng: dng tay kp kn m da li trnh kh trn vo khoang mng phi sau dng gc vaselin bng kn li Nu c y lnh ht th gn vo ng ngn. Ngi ln ht p lc 15-20 cm H2O, tr em ht p lc 10-20 cm H2O

BI 5: CHM SC HU MN NHN TO TRN BN C HMNT1-

HMNT CHA X MING: thng 24- 48h u on rut a ra cha x ming, HMNT c bao ph = gc thm vaselin - Khng TB nu bng kh hoc ch thay lp ngoi nu bng thm t dch mu - Lun lun gi m nim mc HMNT - Chun b x ming HMNT: thng sau 48h PTV s x ming HMNT BNH NHN:

a-

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Chun b v tm lTrang 46

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Nghing BN v pha c HMNT Qun gc thm vaselin quanh chn HMNTb-

DNG C:

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Mm dng c x HMNT hoc mm thay bng ct ch nu PTV x ming HMNT trong phng m v khu thnh ming ti Ti ng phn 2- HMNT X MING: i vi HMNT bn tri hay a i trng ra da: Trong vi ngy u nn bi pomade oxyt km ln da quanh HMNT nga rm l da ( Nu dng ti t ch ) T/bng HMNT khi gc che chn HMNT thm t dch hoc khi phn y 2/3 ti Theo di tnh trng v s hat ng of HMNT Sau khi x ming HMNT rut c th f n hay chng, hoc fn qa cng khng ra c D nn mang gng c tm cht trn nong nh nhng vo ming HMNT v ly fn ra or dng ng thng bm 100 200ml H2O mui sinh l kch thch nhu ng rut v lm mm fn ng cao su hoc que thy tinh gi c nh quai rut thnh bng s c rt ra sau 5 -7 ngy /v HMNT bn fi hay a rut non ra da: c/sc ging HMNT bn tri v cn ch : T/di s mt nc in gii T/di nc xut nhp Cho BN ung nhiu nc Phng nga rm l da quanh HMNT tch cc v y l dch lng

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Trang 47

BI 6: CHM SC BN SAU M KH QUN 1- NGUYN TC CHM SC BN C MKQ: Gi thng ng th: Ht m nht thng xuyn: p dng k thut v khun Nghe phi trc khi ht m ng ht nh hn hoc = 2/3 ng knh canule t ng v tr ri mi ht( ngi ln 8-12cm, tr em 5-6cm) Thi gian ht khng qa 10giy Ht = 2 ng ring bit: 1 cho mi ming, 1 cho MKQ Lun m bo oxy trong qa trnh ht, nu trong t/gian ht BN tm ti th nn ngng ngay v cung cp oxy cho BN. Tr trng hp cp cu D lun cho th oxy ti a trc khi ht m

Bit cch chm sc MKQ: TBng khi gc che chn MKQ thm t or TB mi 4h Cho BN ngi oxy m2- CC BIN CHNG: Cch phng v x tr

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Tc nghn ng th do cc mu ng trong nhng gi u sau m: D ht m thng xuyn trnh cc mu lm tc nghn ng th Chy mu: thng chy mu trong nhng gi u sau m. T/d s lng mu chy v bo BS Tc nghn /th do m nht: HNht t/ xuyn v nghe fi trc v sau khi ht Thiu oxy, ngng th khi ht m: ngng ht ngay v cung cp oxy cho BN St ng trong nhng ngy u: Dng kim banh rng vt MKQ Cho BN th oxy ngay Gi ngi n gip Ph gip BS t li MKQ Theo di st h hpTrang 48

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Trn kh di da: theo di kh th Nhim trng chn MKQ: ra sch v thay bng khi m t Vim phi: ht m, bo m h/thng ht m v trng, h/dn BN ht th su Kh phi xp phi: cho BN th oxy m D kh thc qun: t/di p lc bng chn, thay ng khi c y lnh

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BI 7: CHM SC DN LU KEHR TRN BN SAU M TI MT1- MC CH:

Gai p sau m iu tr Theo di Lm nng tn si qua Kehr Dch mt lun c chy ra ngoi lin tc qua dn lu Kehr ngay sau m Quan st chn dn lu c thm dch mt khng? Nu c nn thay bng ngay v nu cn th t my ht qua chn dn lu. Nga rm l da tch cc cho BN H thng dn c hot ng thng tt: cu ni xung thp di chn ging, khng c nm cn ln dn lu, khng t ct ng dn lu

2- THEO DI S LNG DCH MT:Trang 49

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Thng khi BN cha c nhu ng rut rong 3 ngy u sau m th dch mt qua Kehr hi nhiu khong 300 600 ml/ngy Khi c nhu ng rut lng mt ra dn lu s gim xung 200 ml mi ngy D nn ghi chnh xc s lng mu sc tnh cht dch mt mi ngy Trng hp Kehr khng ra mt hay qa t. D cn xem li: do BN thiu nc, si kt, gp ng, si bn, cc mu ng

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3- THEO DI TNH CHT MT: -

Ch khng c gi cao bnh hng dch khi quan st, trnh dch t ngoi chy ngc dng vo trong Bnh thng mt vng trong ng nh Nu mt ln cn c mu cc: theo di chy mu Nu mt mu trng c: theo di c m Nu mt nu ln cn: theo di cn si

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4- BM RA NG MT:

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D s bm ra ng mt nu c y lnh: Ngun nhn do cn si hay m D bm vi nc mui sinh l v trng m, p lc nh Bm ra 5- 7 ngy lin tip dch mt s trong Khi bm ra lu : p lc nh, BN c au, cng vng bng th nn ngng v theo di

5- RT KEHR:

iu kin: - Thi gian 7-10 ngy sau m - BN ht au, ht st, n ung bit ngon - Dch mt ra gim, vng trong - Siu m ht si - XQ bm thuc cn quang qua kehr kim tra: cc nhnh ng mt thng Chun b rt: - Khi chp XQ xong nn cho Kehr chy ht thuc cn quang ra ngoi sau kp ng Kehr liTrang 50

- Nu sau khi ct BN cm thy st, n khng ngon th nn m Kehr ra v cho dch mt chy ra ngoi, sau ct li v tng dn thi gian cho n khi BN thch ng, thi gian t 24 48 gi th rt

Trang 51

BI 8: CHM SC BNH NHN C DN LUA1-

CHM SC BN SAU M C T DN LU: NHN NH TNH TRNG BN

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Da chung quanh chn dn lu c , nhim trng, x dch Phi bit c dn lu loi g, t u H thng cu ni ng nguyn tc khng? Quan st s lng, mu sc, tnh cht dch chy ra, c bm ra khng, ngy th my sau mB-

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CHM SC:

1- CNG TC T TNG: Bo cho BN bit c t dn lu trc m. D gio dc BN cch chm sc v sinh hot khi c dn luTrang 52

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Nm nghing v fa dn lu, khi i ng di chuyn khng dch chy ngc vo trong Gi vng da chung quanh dn lu v h thng cu ni sch s Khng t ct ng, rt ng 2- CHM SC BN

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Ra sch vt m trc, dn lu sch trc, nhim sau Cung cp y nc, in gii cho BN trong thi gian c dn lu Thay bng khi thm dch Bng dn lu nn cch ly vt m, vi vt thng nhim trng, hay vi hu mn nhn to Nu c chy mu th bo BS, theo di du hiu sinh tn T/di du hiu mt nc in gii trong trng hp s lng dch ra qa nhiu trong ngy Phng nga rm l da tch cc nu dch c tnh cht n mn da Cho BN nm nghing v pha dn lu, trnh BN nm ln ng dn lu Lun cu ni dn lu xung thp 60 cm3- RT DN LU: rt khi c ch nh

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Dn lu nga: rt sm 24 48h sau m v dch ra t di 50ml/ngy Dn lu iu tr: rt khi t mc ch iu tr v gii phu Sauk hi rt: + Cho BN nm nghing v l dn lu va rt + Theo di nhim trng vt thng + Theo di dch x d + Thay bng cho n khi lnh

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Rt dn lu bng: + Khi rt dn lu bng nn xoay ng khi rt, tr dn lu kehr + Khi rt dn lu bng nn bo BN ht th su gip mm bng, rt t t. Nu thy c km theo mc ni th dng li ngay v bo BSTrang 53

+ Theo di dch x d qua vt thng Dn lu p xe : rt t t mi ngy 1- 2cm, gip lnh t y vt thng lnh ra Dn lu u: nu khi rt c m no ( dch trng ln cn ) km theo th ngng ngay Dn lu xng: thng dng bnh ht p lc m, rt ng khi ht dch v rt 1 ln

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BI 9: CHM SC BN SAU M VIM RUT THA A- NHN NH: Tnh trng bng Vt m Dn lu Vn au sau phu thut B- CAN THIP D:1- VIM RUT THA N SM:

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Khi BN tnh cho BN nm t th Fowler Gip BN ngi dy sm, i li quanh ging nga bin chng vim phi v lit rutTrang 55

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Sau 6 8h BN tnh, rt tube Levin, cho BN ung t nc khi BN c nhu ng rut th cho BN n ung bnh thng Vt m v trng khng thay bng, ngy th 6- 7 sau m ct ch Nu m ni soi ct rut tha khng cn thay bng. Cho BN i li cng sm cng tt2- TRNG HP RUT THA C BIN CHNG:

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Thng do rut tha v a n vim phc mc, abces rut tha, rut tha hoi t BN c dn lu: chm sc dn lu bng Cho BN nm t th Fowler nghing v pha c t dn lu Ghi r s lng, mu sc, tnh cht vo h s Dn lu phng nga cn bo BS rt sm Nu dn lu m rut tha thng rt chm hn. Khi c ch nh rt th rt t t mi ngy 1 2cm cho n khi ng t st ra

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Vt m: Trng hp khu da tha: D thay bng hng ngy, ghi li tnh trng vt thng mi ngy Trng hp vt m h da hay nhim trng: thay bng khi thm dch, khi vt m c t chc m ht tt th khu da th hai3- THEO DI V CHM SC BN C BIN CHNG SAU M:

1- Chy mu do tt ch khu ng mch rut tha:-

Theo di:

+ Mu chy qua dn lu + au bng + Huyt p tt, mch nhanh, da xanh, nim ti, v m hi

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X tr: D cn pht hin sm, hi sc v chun b BN m li 2- Chy mu vt m:

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Mu thm bng vt m thng xy ra rt sm vi gi sau m X tr: + D dng gc thm oxy gi n ngay vo ch chy + Nu mu vn chy vi s lng nhiu nn bo BS khu mch mu, ng thi ghi li s lng mu chyTrang 56

+ Theo di DSH 3- Tc rut: -

Thng xy ra vo ngy th 3 4 sau m hay mun hn au bng tng cn, du hiu rn b, du hiu quai rut ni, b trung i tin Gas ( - ) X tr: phng nga cho BN ngi dy sm, ht th, tp vn ng bng sau m 4- Abces v vim ty thnh bng:

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au vt m c gia tng khng, quan st bng c thm t, mi hi khng? X tr: + M bng quan st du hiu nhim trng: sng, nng, , au + Nu c tnh trng nhim trng: ct ch, ra sch m, thay bng v nn ghi vo h s tnh trng vt m, ct bao nhiu mi ch +Thc hin thuc khng sinh theo khng sinh +Theo di DSH: ch nhit 5- Abces ti cng Douglas:

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Nhit tng, BN mt i cu nhiu ln, tiu chy, au bng Thm khm trc trng thy ti cng Douglas phng v au X tr: chun b BN m li 6- D phn:

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Khi thay bng thy dch mu vng ln cn, thi, chy ra ni vt m hay qua dn lu X tr:+ Ghi s lng v tnh cht phn + Chm sc thay bng thng xuyn, trnh rm l da + Hng dn BN cch n ung nhiu dinh dng gip mau lnh ng d4- GIO DC BN KHI RA VIN:

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V sinh vt m C th ct ch vt m a phng Pht hin sm du hiu tc rut sau m: au bng tng cn, b trung i tin th nhn n ung v n BV ngayTrang 57

BI 10: CHM SC BN SAU M VIM PHC MC 1- NHN NH TNH TRNG BN: Tng trng Du sinh hiu Vt m Dn lu au 2- CAN THIP D:-

T TH NM: BN m cho nm u = mt nghing 1 bn, tnh cho nm t th Fowler THEO DI ST DSH: Gup pht hin v ngn nga chongTrang 58

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H HP: Cho th oxy v thng ng th cho BN, v lng kch thch BN ho khc m trnh bin chng vim phi v gip BN sm phc hi nhu ng rut THEO DI ST NHIT : T/di du hiu nhim trng tin trin Theo di st lng nc xut nhp, du hiu mt nc SONDE D DY: trnh tc nghn nn ht lin tc hay ngt qung, ghi li s lng mu sc, tnh cht vo h s. Rt khi c nhu ng rut Theo di tnh trng bng of BN: au, chng THEO DI DN LU BNG: Nu c mu ti nn bo BS, m bo h thng v trng, c th ht ngt qung. Rt dn lu sm, ghi li tnh trng dn lu, cho BN nm nghing v pha dn lu Chm sc khi BN tnh: cho BN ngi dy sm v i li Nga nhim trng tit niu: rt thng tiu sm khi BN n nh CHM SC VT M: Thng sau m vim phc mc phu thut vin may da tha hay h da nn D cn thay bng thng xuyn gip vt m mau lnh DINH DNG: BN vim phc mc rt suy kit sau m do nhn n lu ngy v tnh trng nhim trng km theo v th vic nng cao th trng BN rt cn thit sau m Nu BN cha c nhu ng rut nn thc hin truyn dch ng m Nu BN c nhu ng rut nn cho BN n v cung cp thc n nhiu dinh dng: protit, vit C, A, D Thuc v khng sinh: thc hin ng v chnh xc Gio dc BN khi xut vin: nn t/ di cc du hiu tc rut, p xe tn lu v ti khm ng hn.

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BI 11: CHM SC BN SAU KHI B BT1- TNH TRNG BT C B:

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Khng c che ph bt: v lm lu kh Nm trn ging c mt phng cng khi bt cha kh Khi nng bt nn nng = lng bn tay Ct xn nhng phn p, hn ch cc phn khng cn bt ng, trnh gy chn p nht l b bt khng n Rch dc bt gip gii p khi bt kh. Trnh bt qa cht, gy p Chi b bt c vt thng cn m ca s trn bt c/sc v theo di vt thng Theo di cht tit thm ni bt, mi bt Gi bt lun sch s v kh ro Khng lun vt cng vo gia lp bt v da gi Khng rt gn n bn trong bt 2- TNH TRNG CHI B BT:

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T/di cc du chng quan trng gy ra do chn p trong 12-24h sau khi b bt nh d/hiu 5 P: Pain Paresthesia Pallor Paralysis

(au ) (t, yu ) ( ti ) ( lit ) ( mt mch)

Pulselessers

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Cn rch rng bt v nng cao phn chi b bt gim ph n T/di s chn p cc b: do b khng u tay hay do p t u xng T/di s chn p ton chi b bt: do b qa cht hay do tnh trng ph n sau chn thng tng Kim tra bt b c va hay qa lng Tp co c trong bt trnh teo c, cng khp Tp c ng cc u chi ni bt bTrang 60

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3- CHM SC DA: -

Chm sc da sch s hng ngy Thng xuyn quan st vng da ni cc mp bt nht l cc vng p nh vng gy khuu, gai chu, xng cng. Pht hin s c st ph n hay i mu da, lot Hng dn BN cch t/di chm sc da trnh tn thng da. Dng gng xem nhng vng khng xem c trc tip Khng lun vt cng vo gia lp bt v da gi Khi xoay tr BN cn phi ly ra nhng mnh bt vn, quan st da BN, t th nm of BN chm sc thch hp Gii thch cho BN hiu rng lm xc mt trong bt khng an ton v lm tn thng da v gy nhim trng da Khng rt gn n hoc nht thm gn vo bn trong gia lp bt v da Lau sch cc u chi b bt, xoa bp, massage mi ngy kch thch da

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BI 12: CHM SC BN KO T1- TON THN: H hp, nhit , v sinh c nhn 2- NI XUYN INH: Hng ngy theo di du hiu nhim trng ni xuyn inh 3- H THNG KO T:

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Hng dy ko phi trng vi hng of trc chi nh gi lc t ko i v lc phn ko k cao chn ging: u cao khng qa 15 H thng rng rc phi trn nhn v hat ng tt Cc nt dy buc phi chc, dy treo phi l lng khng chm vo ging hay sn, trc dy thng, dy chc T cch mt t trung bnh 20 cm, t khng u a trnh rt Khi di chuyn BN nn c nh t vo thnh ging Khi buc thm t ko tng trng lng, phi theo ng y lnh, thao tc nh nhng th t t t 4- CHM SC DA:Trang 61

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Kim tra m ni da tip xc, nhit mi trng mt, trnh m cao V sinh da xung quanh sch s, lau kh m hi. Trnh m t cc vng d b hm l Hng dn BN t thay i t th: Chng chn lnh xung ging lm thong vng da mng v vng cng ct Xoay vn nh phn lng sang 2 bn Xoa bp vng d b lot t Nm x treo ni u ging ngi dy, vn ng chi trn v cc c ngc bng 5- CHM SC T TH:

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BN ko t khng c nm nghing hay nm sp BN phi nm thng gia ging, u bng hoc u thp, khng trt v pha t ko Khng c dng gi lt chi ko t Chn ko t dang nh # 300 Bn chn vung gc vi cng chn, dy ko nm gia ngn 1 v 26- TP LUYN:

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Bn c vn ng, xoay tr nh nhng sang bn ang ko, trnh gy nh hng ni t ko t Vn ng cc phn chi cn t do trnh teo c, gng c chi ko t Th su, vn ng bng Tp c ng tay chn bn lnh gip s dng nng sau khi tho t 7- T CHM SC GII TR:

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BN rt chn nn do nm lu: D to mi trng thong mt, thoi mi, v sinh, n ung, c sch, xem tivi, nghe nhc

IU DNG NI KHOATrang 62

BI 1: CSBN LOT D DY T TRNG 1- GIM AU:

BN nm ngh ngi khi c cn au ngoi cn au khuyn BN nn lm vic t t, trnh lo u, bun phin trnh cn au ti pht, thc hin thuc theo y lnh: Nhm Antacid: Phosphalugel, Maalox, Alumina thuc trung ha HCL c bi tit. Ung nhiu ln trong ngy, ung sau khi n 30 pht v s i qua d dy c chm li do c thc n trong c ch cm th H2: Cimetidin, Ranitidin c ch bi tit HCL. T/di t/dng f nh gim bch cu, to bn, v to nam gii, trm cm c ch bm Proton: Omeprazole, Lomac, Losec c ch bi tit HCL Cc thuc bo v nim mc Scralfate, thuc gp HCL chuyn thnh mt lp dnh qunh gn trn lot, hng ro ny khng axit Thuc dit khun Helicobacter Pylori

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Khuyn BN trnh ung, t/n c nhiu gia v, cafev kch thch nim mc DD

H/dn BN n chm, nhai k v mu thc n cng nh cng tit t axit H/dn BN ung nhiu nc v nc c xem l cht khng axit tt Khuyn BN n thnh nhiu ba nh trong ngy 2- CH AN THCH HP: Mc tiu of ch n l trnh bi tit qa nhiu v tng co bp DD. C th gim thiu 2 vn trn = cch trnh cc khc bit thi qa v nhit v kch thch mnh = nc tht p, ru, cc gia v, caf. Thc n ngt, bo gy tit t dch v Khuyn BN dng thc n, ung khng c cht kch thch. Khng nn dng cc thc ung hp c nhiu hi, cc thc n chua, cay. H/dn BN bit tc hi of ru, thuc l

Ru l cht kch thch mnh: nng ru cao s ph hy hng ro bo v nim mc DD v gy kch thch xut tit mnh Thuc l: lm tng ri lon c/ nng v/ ng of DD-TT -> lm tng q/trnh ri lon t/ hon ti cc m, t/ chc TBo v vy lm chm lnh lot v t l ti ft cao Khuyn BN chia lm nhiu ba nh trong ngy Thc n mm, d tiu, trnh cc ba n chiu qa mun, n qa no. To khng kh th gin, khuyn khch BN n, gip BN gim lo u, gim tit axitTrang 63

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3- GIM LO LNG: -

Khuyn khch BN trnh by vc thc mc, s lo lng..gip BN tin cy gim lo lu Gai thch cc l do phi tun theo iu tr Hng dn BN cch lm gim stress 4- PHNG BIN CHNG:

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Khuyn khch BN tun th t/gian iu tr m bo cha lnh hon ton lot v gim thiu cc b/ chng. V phn ln cc BN ht t/ chng trong 1 tun nn D cn nhn mnh tm quan trng of vic t/di ch /tr trnh f v qa trnh lnh bnh v lot tr thnh mn tnh Hnd dn BN cch nhn bit binchng

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XHTH: i ra mu, tiu phn en, mch nhanh, HA tt, kh th, vt v

Thng: au bng d di, bng cng Hp mn v: nn, bun nn, bng chng du c ch Ung th ha 5- GIO DC SC KHE C ch lm vic v ngh ngi thch hp khng lao ng nng Khng s dng thuc ba bi, ung thuc theo ch nh of BS, trnh cc thuc kch thch nim mc d dy: corticoid, Aspirin Hn ch caf, tr, gia v. n chm, nhai k, ngh ngi t nht 15 pht sau khi n Khuyn BN b ru , thuc l, trnh xc ng mnh, cng thng thn kinh Hng dn cch nhn bit bin chng iu tr ng thi gian v ti khm ng hn

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BI 2: CSBN XUT HUYT TIU HA TRN1- KHI PHC KHI LNG TUN HON:

Mt mu nh: -

Ngh ngi ti ging Phc v sinh hot ti ging: n ung, v sinh c nhn Theo di tnh trng lm sang of BNTrang 65

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Theo di cc xt nghim mu: Cng thc mu, Hemoglobin, Hematocrite Mt mu va v nng

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Khn trng chun b ng truyn TM trong thi gian ch cc kt qa xt nghim t BN nm u bng, mt nghing 1 bn ( trng hp BN nn ) Cho BN th oxy nh gi mc gim th tch tun hon T/ di st DSH , da nim, tri gic cho n khi BN ra khi tnh trng cp cu T/di cc xt nghim v mu, chun b th tc xin v truyn mu Tr gip BS x tnh mch hoc t C V P ( nu cn ) T/di mu sc, s lng, tnh cht nn v phn t ng thng mi d dy : ra d dy, d phng nn, t/di chy mu, cho thuc t ng thng tiu t/di theo y lnh T/ hin cc y lnh v thuc, dch truyn t Blakemore ( trng hp BN XHTH do v gin TM thc qun ). Chun b BN ni soi cp cu, vi ni soi ngi ta c th bit c n/nhn chy mu, m/ chy mu, mu ang chy hay cm, t/ hnh cm mu tc thi Phc v v sinh ti ging 2- CH N UNG:

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Ch cho BN n khi khng cn nn ra mu Nui n = ng truyn TM trong trng hp BN khng n ung c Cho BN n t lng n c, chia lm nhiu ba nh trong ngy Thc n d tiu, khng dng nhiu gia v, trnh cht kch thch nh ru, caf, thuc l3- DUY TR V SINH C NHN :

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Tr gip v sinh rng ming, sc ming = nc m sau khi nn Thay drap ging, qun o khi d m bo an ton trnh t ng 4- GIO DC SC KHO:Trang 66

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H/dn BN cch pht hin sm tnh trng XHTH v iu tr sm T/hin ch n thch hp, trnh thc n c nhiu gia v, cht kch thch Thn trng khi s dng cc thuc Aspirin, Corticoid khi BN c tin s lot DDTT Cn c ch lm vic v ngh ngi thch hp, trnh lao ng nng Trnh lo u cng thng Ti khm ng hn, kim tra sc khe nh k BI 3: CHM SC BNH NHN X GAN1- GIM MT MI:

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BN c c ngh ngi nhm lm gim nhu cu of c th v tng c/ cp mu cho gan. T th t/ hp t c h/qa v h hp nht l trong trng hp BN c c chng C/cp ch n giu m ( ch hn ch trong trng hp BN da hn m gan ), giu nng lng, b sung sinh t A, B, C, K c/cp nng lng cho vn ng ng vin, hng dn ch ngh ngi v vn ng thch hp2- TNH TRNG DINH DNG C CI THIN:

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BN x gan cha c c chng, ph v cc d/hiu of hn m gan cn c c/ n giu m v sinh t ng vin BN n ung, n nhiu ln trong ngy, mi ln 1 t c dung np tt Thc n hp khu v, c trnh by p mt B ru nhm kch kch d dy V sinh rng ming kch thch khu v T/hin y lnh v thuc: chng nn, tiu chy, to bnnhm gim triu chng tiu ha v cm gic kh chu K/ sot ch n mt cch cht ch, khi thy c t/chng NH3 tng fi gim lng protid kp thi3- PHT HIN SM TNH TRNG RI LON THC:

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nh gi tnh trng tri gic To /kin BN ngh ngi tt nh phng bnh tin nghi, hn ch ngi thmTrang 67

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Hn ch khu phn m nh ch nh Tng cng cht bt ng c/cp nng lng cho BN An ton cho BN, bo v BN trong trng hp co git Bo v BN trnh nhim trng nhm lm gim nguy c tng nhu cu chuyn ha T/di st thc of BN T/hin cc y lnh tht tho, thuc ( cn thn khi dng thuc m, thuc ng phng nga cc du hiu hn m gan b che khut )4- GIM NGUY C XUT HUYT:

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Quan st cht nn v phn of BN pht hin chy mu ng tiu ha

Cnh gic trc t/chng chng thng v, mt mi, bn chnnhm pht hin sm chy mu -

Th nghim phn, cht nn nu nghi ng xut huyt

Q/st t/di cc biu hin of chy mu: chy mu cam, chy mu rng ming, vt bm da kinh Theo di DSH Cho BN ngh ngi, gim vn ng gim nguy c chy mu v cng thng thn Tim sinh t K, sinh t C theo y lnh Tin hnh cc bin php phng xut huyt: Mi trng an ton Cung cp bn chi nh rng loi mm S dng kim nh tim Ghi chp v tr chy mu 5GIM NGUY C TN THNG DA:

Chm sc da cn c quan tm do tnh trng ph, nga da, v vn ng hn ch lm tng nguy c tn thng da Tng cng chm sc da, lm m da trnh da kh v bt nga. Trnh dng cc loi x bong gy k/ thch v bng keo gy k/ thch da. Ct mng tay cho BN trnh co xt daTrang 68

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T/ i t th thng xuyn cho BN phng chng lot t. Chm lt cc ni d b cn T/ di cn nng BN gip t/di t/ trng gi nc v mt nc. Hn ch mui gim ph K cao chi ph Nhn xt ghi chp mc vng da nhm pht hin cc thay i

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BI 4: CHM SC BN TNG HUYT P1- GIM MT MI:

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Phng bnh yn tnh, thong mt, trnh thay i nhit t ngt T/ hp BN THA nng cn c ngh ngi ti ging v cn t/di c/ ch theo y lnh of BS BN c th lm nhng c/ vic t phc v mnh, i li trong phng, tp v/ ng nh nhng Trnh cng thng thn kinh, hng dn cho BN cc bin php th gin

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2- CH N UNG NG:

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H/dn ch n gim mui. Cung cp danh sch mt s loi thc n t natri nh: tht, c, trng, sa, rau, hoa qa ti, cc loi nc p tri cy, cc loi gia v, rau thm Mt s loi thc n cha nhiu natri m BN cn bit hn ch nh: tht mui, tht, c ng hp, cc thc n nu sn trong nh hng, rau, c ngm dm, cc loi bnh phng tm, khoai ty chin c mui, cc loi nc st, bt ngt Mt s loi thuc c cha natri nh cc sir ho, cc thuc nhun trng, thuc an thn..BN nn tp thi quen c cn thn nhn thuc. Nu nghi ngi hi BS hoc dc s xem thuc c ph hp khi s dng khng Gim bo, nn thay m = du thc vt. hn ch lng cholesterol tng cao trong mu, ch n cn tng cng cht x, tp th dc u n, hn ch n nhiu tht gia cm v hi sn. Nn n cc mn c/cp m t thc vt nh cc loi u, cc loi sa t bo. Hn ch lng trng, ph tng ng vt Gim c/cp nng lng nu BN d cn Khuyn BN trnh dng cc cht kch thch caf, ru Khng ht thuc v nicotin gy co mch

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3- AN TON KHI S DNG THUC IU TR TNG HUYT P: T/di nhp tim, o HA cho BN trc v sau khi dng thucTrang 70

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Cho BN ung thuc li tiu vo bui sng trnh nh hng ti gic ng of BN Vi cc thuc gy h p mnh cn khuyn BN nm ngh sau khi ung thuc 30 pht H/dn BN cc t/dng ph of thuc nh: chn n, mt mi, bun nn, tai, ni mn

4- GIO DC SC KHE: A/ Cung cp kin thc v bnh tng HA -

L bnh nguy him gy nhiu bin chng iu tr ng lm gim nguy c gy b/chng, gim t l t vong. Nu khng kim sot tng HA c th l nguyn nhn gy t qy, cn au tim V nguyn nhn cha bit r nn phi iu tr sut i B/ Thuyt phc BN iu tr sut i:

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Cn phi t/ xuyn t/di HA ti ni thun tin. C th h/dn Bn cch t o HA ti nh, iu ny li cun BN vo s t chm sc Khuyn BN ung thuc lin tc theo toa of Bs, cn nhn mnh vic b khng dng thuc c th dn n s tng HA. i vi BN ln tui vic dng thuc c th l 1 v/ q/ trng v i hi vic dng thuc lin tc, nhiu liu trong ngy v c th c bit tn km vi nhng ngi c thu nhp thp. Cn ch trng /bit bit chc rng BN hiu c ch dng thuc v c c cc ch dn v c th c/cp thuc y cho nhng n thuc k tip. V vy gia nh BN ln tui cn hiu c nhu cu of BN, h tr ng theo chng trnh iu tr. BN cn c t/bo v t/dng chnh v f of thuc duy tr c/trnh t dng thuc an ton BN bo co t/dng f of thuc trc khi thay i hoc ngng thuc n khm khi c cc b/hin sau: nhc u, kh th, au ngc, ph, t hoc gim v/ng C/ Thuyt phc BN thay i li sng ph hp:

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Khng lao ng tr c qa mc, trnh stress tm l Lao ng chn tay nh nhng, th dc liu fp, i b c li cho sc khe of BN H/dn ch n thch hp. Gip BN qa cn c k hoch gim cn. Loi b cc thc n c nhiu mui: khoai ty chin, thc n ng hp Cung cp danh sch nhng thc n c t mui cho BN Khuyn BN v gia nh h ghi li cc thuc s dng v cho BS iu tr bitTrang 71

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BI 5: CHM SC BN SUY TIM1- BN GIM MT MI:

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Gup BN ngh ngi. V:Trang 72

Lm gim mc lm vic of tim Lm tng s ti mu thn -> tng bi niu Khng lm tng tn s tim, lm tng hiu qa co bp c tim -

T th BN: t BN nm u cao, hoc na nm na ngi Thi gian ngh ngi hon ton ny thng ko di t vi ngy n vi tun cho n khi suy tim gim bt Khi suy tim gim cho BN v/ ng va fi lm tng dng mu n thn, ngoi bin Ch thay i t th thng xuyn, tp th su, xoa bp 2 chn lm cho mu TM tr v tim tt hn. Vn ng tr liu trnh thuyn tc mch T/ hp BN suy tim nng BN phi nm bt ng ti ging. D fi p ng mi nhu cu v v sinh c nhn

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2- BN GIM LO LNG TRNG CNG THNG:-

Nn cho BN nm u cao v n ban m + s c mt of 1 thnh vn trong gia nh l iu cn thit BN yn tm Theo di pht hin nhp th khng u Cho BN th oxy theo y lnh Gip BN ngh ngi

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3- BN AN TON KHI DNG THUC:

Theo di DSH v lng nc xut nhp hng ngy Theo di p ng of thuc v tc dng ph nu c THUC TR TIM NHM Digitalis m mch trc khi cho BN ung, nu mch < 60 l/pht th ngng thuc v bo BS Theo di cc du hiu ng c: chn n, bun nn, thay i nhp tim, au u

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THUC LI TIU: Nhm thi Kali hoc tit kim Kali Cho dng vo bui sng ( hoc trc 15h ) khng tr ngi cho gic ng m Ghi lng dch xut nhp Cn BN hng ngy cng 1 thi gian, kim tra BN pht hin ph, mt ncTrang 73

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T/di t/dng ph of thuc: Gim Kali huyt ( mch yu, ting tim khng r, c nho, gim phn x gn c v suy yu ton thn ) T/di ion trong mu phng gim Kali trong mu, gim Natri trong mu B/ sung Kali cho nhng BN thiu Kali = dd KCl or tri cy c nhiu Kali:chui, cam, nho THUC DN MCH:

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Cho BN nm ti ging Theo di HA

4- CH N UNG:-

Nu c ph th hn ch mui. Cc trng hp suy tim nng phi n lt tuyt i, nu n khng c nm mui, nc mm n y cc cht b dng Ung khi kht Trnh caf, thuc l

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5- GIO DC SC KHE: -

BN phi nghim tc tun theo chng trnh tr liu ch nh Khuyn BN trnh nhng cng thng v cm xc Hng dn ch ngh ngi, n ung, cch xoa bp, vn ng, cch dng thuc theo toa BS v ti khm, ng hn. Duy tr trng lng thch hp iu tri bnh phi hp Sinh hot iu trnh gng sc Bit cch nhn bit nhng triu chng bt thng nh tng cn, chn n, kh th khi hot ng, ph chn, bng bng, ho dai dngphi n bnh vin ngay

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BI 6: CHM SC BN I THO NG 1- DUY TR NG HUYT MC BNH THNG: Ch n ng: giu cht x, vitamin, gim bo-

Cht x c v/ tr q/ trng trong c/ n nh cht n c t/dng lm gim cholesterol, nga to bn Ch n hng ngy c protid chim 15- 20%, lipid khng qa 30%, glucid chim 50- 55% tng s calo/ngyTrang 75

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Hn ch ng hp thu nhanh( mt, bnh ngt, nc ngt) s dng cc cht to v ngt nu BN thm n ngt Hn ch ru, bia khi s dng thuc h ng huyt v c th gy h ng t ngt Dng lng mui va phi ( < 6g/ngy ) Theo di cn nng, gim cn trong trng hp BN qa cn Tun th y lnh v thuc Duy tr h/ng th lc mc cho php: Tp luyn c t/dng tng nhy cm insulin, c nhng li ch v chuyn ha, tim mch, tm l. Tp luyn cn ph hp la tui, sc khe v s thch c nhn. Nn tp nhng mn rn luyn s do dai ( i b, xe p, bi li ) Hng dn BN cch theo di ng huyt v phng h ng huyt

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2- DUY TR S TON VN CA DA Hng dn BN thng xuyn kim tra da pht hin cc tn thng da Tng cng v sinh c nhn Xoay tr nga lot Chm sc chn phng bin chng -

Kim tra chn hng ngy nhm pht hin cc tn thng nh: ch phng, cc chai, b S dng gng nu cn q/ st sau lng or bn chn. Ra chn hng ngy = nc m Lm kh chn = khn lng mm, ch k ngn chn, s dng kem lm m da Ct ngn mng chn, tay, ch khng ct qa st, ct khe Mang giy ng kch c. Khng mang giy cao su, nhaKhng i chn khng iu tr ti cc c s y t khi c vt thng chn

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3- PHNH TRNH CC TN THNG:-

Lng gi mi trng xung quanh c nh hng n s an ton ca BN: sn nh t, dy in, thiu nh sang li i. Nhc nh BN Ci thin mi trng nu cn thit ngh gip trong trng hp BN qa yu

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4- PHNG NGA BIN CHNG: Trang 76

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Nhn mnh tm quan trng ca vic duy tr ng huyt. Khuyn BN khng ht thuc l T/di cc b/chng mt, tim mch, chn, hn m, t/trng tng hay h ng huyt

H NG HYT: Theo di ng huyt v cc triu chng h ng huyt: run ry, i, gim thc Th li ng huyt sau khi iu tr 15- 30 pht TNG NG HUYT:-

Theo di ng huyt v cc du hiu tng ng huyt: kht, tiu nhiu, bun ng Thc hin y lnh: insulin, thuc h ng huyt dng ung Khuyn khch BN tun th iu tr: ch n, thuc, luyn tp th dc

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5- GIO DC SC KHE: Thc hin ng ch n ung Theo di ng huyt, ng niu thng xuyn Ti khm nh k nhm pht hin sm bin chng v iu tr kp thi Tng cng v sinh c nhn Tp th dc thng xuyn

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BI 7: CHM SC BN TAI BIN MCH MU NO 1DUY TR TI MU NO Y : - Theo di st thc theo thang im Glasgow - Theo di du sinh hiu - Thc hin thuc theo y lnh: chng ph no, chng ng, gin mch - Khi CSc trnh nhng hat ng gy tng p lc ni s: t th cong gp hng, c, ho 2- TNG CNG KH NNG VN NG V T CHM SC: - Tp vn ng th ng nu mt hon ton vn ng. Luyn tp ch ng khi fc hi 1 fn - Luyn tp tt c cc c v khp bn lit - Luyn tp 2-3 ln/ngy, xa cc ba n - Cn thn khi nng , vn chuyn BN - Khuyn khch BN t chm sc - Hng dn BN t chm sc - Cung cp phng tin h tr: xe y, gy -Cung cp ch n nng lng BN c th luyn tp 3- CI THIN KH NNG GIAO TIP: Thay i cch thng tin: ch vit, hnh nh Luyn tp pht m: - T, cm t, cu ngn - Luyn tp nhiu ln trong ngy Khuyn khch BN luyn tp 4- M BO DINH DNG: - Chn thc n mm, c - Thc n cht dinh dng, cn i v thnh phn - Chia thnh nhiu ba nh trong ngy - Nng u ging khi cho BN n - ng vin BN to khng kh thoi mi khi nTrang 78

- Luyn tp, xoa bp c mt - t my ht gn ging BN - Gim s xao lng ( tt ti vi khi BN n hoc ung ) - t tube Levin theo y lnh 5- M BO CHC NNG BI TIT: - Tp i tiu vo 1 gi nht nh - Khuyn khch BN n nhiu cht x, ung nc - Thng tiu v tht tho nu cn - m bo k thut - Kp ng v tho nc tiu gip to phn x BN c th t tiu sau ny - m bo v sinh c nhn sau khi tiu tiu 6- DUY TR TNH TRNG DA NGUYN VN: - Thay i t th mi 2h - Tng cng chm sc da trnh tn thng da - S dng nm nga lot - Tng cng dinh dng - Chm sc vt lot nu c 7- GIO DC SC KHE - Nhn mnh tm quan trng ca PHCN nht l i vi ngi cao tui - Hng dn ch n: gim m, gim mui - Hng dn s dng thuc, iu tr - Khuyn khch s h tr ca gia nh BN - To mi trng an ton.

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BI 8: CHM SC BN NHIM TRNG TIU NTT l c s hin din ca tc nhn gy bnh trong ng tiu nh vi khun, vi rt, nm C CH BO V: - Dng nc tiu y tri, lai b vi trng xm nhp. Khi dng nc tiu b nghn do bnh l th d b NTT - Yu t nim mc bng quang: ngn nga s sinh sn ca vi khun. - PH ca nc tiu c tnh axit ngn cn s sinh sn ca vi trng CC YU T THUN LI GY NTT: - Tc nghn ng tiu do si, u, bu gy ng nc tiu to mi trng thun li cho vi trng pht trin, s ng nc tiu bng quang cn lm gim s tip xc ca vi trng vi yu t nim mc. Bng quang cng lm mu n bang quang gim khin vi trng d pht trin - Cc th thut nh t thng tiu, soi BQuang c th a vi trng t ngoi vo - S tro ngc bng quang niu qun - Do thai k - Cc bnh lm suy gim min dch 1- GIM AU V KH CHU: - Thc hin y lnh v thuc khng sinh c hiu, thuc chng co tht cho BN lm gim cm gic tiu but, tiu kh. Cm gic nng rt mt i nhanh chng - Khuyn BN tm nc m, ngm mng vo nc m cng lm BN cm thy d chu v mt i cm gic au but khi tiu - Hung dn BN ung nhiu nuc tng dng mu n thn, tng lng nc tiu, c tc dng ra sch vi khun khi ng tit niu. Tuy nhin nn trnh cc loi nc ung c th gy kch thch bng quang nh tr, caf, coca - Khuyn BN c 2-3h i tiu 1 ln lm trng bng quang. iu ny c th lm gim s lng vi khun trong nc tiu, lm gim ng nc ti 2- GIO DC SC KHE: - Hng dn BN s dng thuc lin tc theo y lnh ( ngay c khi triu chng bin mt)Trang 80

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C gng lm gim mt vi khun vng sinh dc, niu o = cc b/ php v sinh sau: Tm hng ngy, tt nht l tm di vi nc Ra tht sch vng tng sinh mn, l niu o( ch ra t trc ra sau) sau mi ln tiu, tiu - Nhn mnh tm quan trng ca vic ung nhiu nc hng ngy (t 2- 2,5 lt) lm sch vi khun ng tit niu - Khuyn BN i tiu mi 2 3h ngn nga s cng gin ca bng quang lm ngn cn s cung cp mu ti bng quang - Bo cho BS nu cc triu chng khng gim hay t hn - Bit cch theo di v nhn bit du hiu nhim trng tiu BI 9: CHM SC BN HEN PH QUN CC YU T KHI PHT CN HEN: D ng: - Mi v cht kch thch: phn hoa, xng du, lng, bi - Thc n - Nm mc - Thuc Stress Gng sc Yu t vt l: thi tit thay i, nhit , m, p sut Nhim trng 1. H HP HIU QU - Thc hin y lnh thuc: dn ph qun, corticoid - T th: cho BN nm u cao hay ngi - Ht m nht, v rung phi, hng dn BN tp th, khc m - Chm sc, theo di BN th oxy - Tng cng lng dch vo c th lm long dch tit - nh gi t/trng h hp, t/di DSH, kh mu ng mch, lng nc xut nhp, ion - Hng dn vt l tr liu h hp: th chm mi, th bng ( c honh), th ngc bng 2. PHNG NGA NHIM BIN CHNG: - Thc hin y lnh khng sinh ng v V snh c nhn, phng bnh, mi trng sch s, hong mt Khng ng m nht Dinh dng ng ngh, vn ng hp l Ch iu tr chm sc thch hp D phng cn hen Duy tr chc nng h hp - Duy tr cn bng nc in gii Phng trnh nh hng xu ca thuc - phng cc yu t gy henTrang 81

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C k hoch qun l bnh lu di Theo di BN u n 3. GIO DC SC KHE: TM L: ng vin an i, n cn chm sc BN, lun c mt trong cn hen Gii thch v bnh, cch iu tr, t/di qun l sc khe lu di. Bnh khng cha khi nhng c th km ch c Khng lo s ht hong khi cn hen xy ra

IU TR: - Khng t dng thuc,fi theo y lnh BS, khng lm dng thuc dn PQ, thuc co mch - Ch cc triu chng tin hen iu tr d phng nh: ht hi, s mi, ho khan - Bit x tr khi c cn hen - Ti khm ng hn - Luyn tp thn th hng ngy HNG DN D PHNG HEN: - Tm hiu tin s hen, d ng ca gia nh - Dng thuc theo y lnh - Xc nh yu t khi pht cn hen v c k hoch loi b yu t khi pht cn hen: + Trnh thc n, thc ung gy d ng v cc d nguyn khc + Mi trng sng thong mt, sch s, trnh nui sc vt trong nh, dit gin + Khng ht thuc, trnh mi trng nhim, nhiu khi bi + Git drap ging t nht l 1 ln/ tun + Khng lao ng gng sc + Trnh nhim lnh t ngt + Trnh stress, chn thng, tm l

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BI 10: CHM SC BN VIM PHI A- NH NGHA: Vim phi l hin tng vim nhim ca nhu m phi bao gm vim ph nang, ti ph qun, ng ph nang, t chc lin kt, k h, v tiu ph qun tn cng gy ra bi nhiu tc nhn, l nguyn nhn gy t vong thng gp nht trong cc bnh nhim khun B- CHM SC IU DNG: 1. H HP KHNG HIU QU DO NHIM KHUN PHI - Theo di du snh hiu - T th thch hp d th v thoi mi - Lm long m: ung nhiu nc, v lng, rung ngc - Khuyn khch BN ho khc m, ht m nht, th hiu qu: ht vo mi, th ra qua mi khp kn, tp th su - Kt hp vt l tr liu vng ngc - Cho th oxy theo y lnh - B lng dch vo c th, lm m khng kh th, tng thng kh - Thc hin thuc theo y lnh BS: khng sinh, dn ph qun, vitamin - Theo di tnh trng h hp, thc BN, bo BS khi c biu hin bt thng2. RI LON NC IN GII DO ST CAO V TNG NHP TH:

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Theo di ion , lng nc xut nhp / 24h Ung nhu nc m, sa, nc hoa qu Thc hin thuc v truyn dch theo y lnh B sung thc n c nhiu in gii, vitamin, khong cht: nc da, cam, chanh, nho

3. DINH DNG KM DO MT MI, CHN N: - Ngh ngi ti ging trnh tiu hao nng lng - Thc n giu dinh dng, m bo nng lng - Thc n lng, m, d tiu, hp khu v theo ch n bnh l - Chia lm nhiu ba nh trong ngy - Gim bt ng trong giai on kh th ( sinh co2 )Trang 83

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Nui n qua sonde d dy, qua tnh mch trong trng hp bnh nng Theo di cn nng, ch s BMI cung cp ch dinh dng hp l v an ton

4. LO LNG THIU KIN THC V BNH: - ng vin, an i BN, gip BN hiu mt mi s cn ko di 1 thi gian sau khi bnh - Gii thch s tin trin ca bnh, cch iu tr hiu qu - Dinh dng y s gip bnh mau khi - H/ dn tp luyn c th tng cng chc nng h hp, tp th su, tp ho, tp lm dn n phi - Tun th ch ch iu tr, ti khm ng hn - Loi b nhng thi quen xu cho sc khe: b ru, thuc l - Trnh lm vic qu sc, n ung, ngh ngi hp l - Gi m c ngc v iu tr ng cc bnh thng thng v sau khi vim phi d nhim khun v ti pht tr li - Tim phng cc dch bnh, khm sc khe nh k

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BI 11: CHM SC BN NG C CP BN PHI C LOI B CHT C RA KHI C TH: Ty theo ng gy ng c m tin hnh loi b cht c ra khi c th 1. QUA DA: - Thay qun o - Ra ni tip xc vi cht c =nc, lu trnh ch xt mnh lm thuc hp thu nhanh 2. QUA NG H HP: - S dng cc bin php h tr v h hp: th oxy, t ni kh qun, th my 3. QUA NG TIU HA: GY NN + Ngoy vo thnh hng gy nn + Ung siro Ipeca + Tim Apomorphin + Chng ch nh: - Ng c axit bazo hay cht n mn khng gy nn, tri gic l m, hn m, co git, thnh bng yu, c thai (rch c honh), cao huyt p ( xut huyt no) RA D DY: - Ra = ng Faucher nu BN tnh cho n khi nc ra trong v khng cn mi ca cht gy ng c ( 1 -2 lt nc) - Trng hp BN ri lon chi gic, BN c t ni kh qun trc khi ra = tube Levine nga dch d dy tro ngc - Chng ch nh: ng c cht n mn ( axit, kim ), cht bay hi ( xng, du hi), co git, hn m cha t ni kh qun c bng chn TY X: Mt nc v in gii - Du paraffine - Sunfate Magn THAN HOT: - To phc hp than hot c cht khng c, khng hp thu vo mu - Dng ngay sau ra d dyTrang 85

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Liu 1g 2g/kg/ln, pha vi nc t l , lp li liu mi 4 6g trong 24h cho n khi xut hin than hot trong phn C th kt hp vi thuc nhun trng + CHNG CH NH: Ng c c cht n mn: than hot khng c tc dng v c th che khut ni b phng Khng c nhu ng rut ( lit rut c nng ) C du hiu tc rut, thng rut hay vim phc mc Mt phn x bo v ng th: hn m cha t ni kh qun ng tit niu: nu c cht c thi qua ng tiu ta dng cc bin php gy tiu nhiu: truyn dch, li tiu Cc bin php khc: thm phn phc mc, thn nhn to iu tr c hiu: dng cc cht i khng cng sm cng tt lm gim bt tc dng ca cht c CHT C CHT KHNG C Phospho hu c Atropin, PAM Sn Vitamin B12, xanh methylene Thuc phin Nalorphin Atropin Pilocarpin Ch EDTA Kim loi nng BAL ( dimercaprol ) Chloroquin Diazepam Paracetamol N-acetyloystein An thn Anexat

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BI 12: CHM SC BN SC PHN V 1. TRIU CHNG, HP CHNG SHOCK: TRIU CHNG: - Bn chn, ht hong, s hi - Mn nga , my ay, ban , ph quincke - Mch nhanh nh kh bt, huyt p tt - Kh th, nght th - Ri lon tiu ha - au u chng mt i khi hn m - Chong vng, vt v, gii gia, co git HP CHNG SHOCK: 1. Adrenalin 1mg 1ml 2 ng 2. Nc ct 10ml 2 ng 3. ng tim 10cc 2 ng 4. ng tim 1cc 1ml 2 ng 5. Hydrocortisone 100mg 1 ng 6. Phng tin kh trng 7. Dy garrot 8. Phc chng shock phn v 2. BN B D NG TON THN DO TIP XC VI D NGUYN ( Cch x tr ) - Ngng ngay ng tip xc vi d nguyn - Cho BN nm ti ch, u thp chn cao - Duy tr ng h hp: + Thng ng th, ht m + Cho BN th oxy + Chun b dng c v tr gip BS t ni kh qun, m kh qun, th my - Thc hin y lnh v thuc: + Adrenaline dung dch 1/1000, ng 1ml= 1mg, tim di da ngay sau khi xut hin shock phn v vi liu nh sau: - 1 ng ngi lnTrang 87

Khng qu 0,3mg tr em ( ng 1ml = 1mg + 9ml nc ct = 10ml sau tim 0,1ml/kg ) Hoc Adrenaline 0,01mg/kg cho c tr em hoc ngi ln Tip tc tim Adrenaline liu nh trn 10-15 pht/ln cho n khi HA tr li b/ thng m u thp chn cao, theo di HA 10-15 p/ln ( nm nghing nu c nn ) Nu shock nng e da t vong, ngoi ng tim di da c th tim Adrenaline dung dch 1/10.000 ( pha long 1/10 ) qua tnh mch, bm qua ng ni kh qun hoc tim qua mng nhn gip + Hydrocortisone + Aminophylin nu BN co tht ph qun nng - Thit lp ng truyn nng HA v h tr kh lng tun hon. Nu BN h p ko di, cho thuc nng HA nh Dopamine - Cp cu h hp tun hon nu BN ngng tim ngng th - Diazepam nu BN c co git - T/ di DSH 10-15p/ln, lng nc tiu, in tm cho n khi BN ra khi sc phn v - Theo di ti thiu 48h 3. BN THIU KIN THC V PHNG NGA SHOCK: - Lun lun fi nh hi tin s d ng thuc ca BN trnh khng dng cc thuc - Hi BN v tin s d ng thc n, d ng phn hoahen PQ, d ng da - Lm test da vi tt c cc thuc, cc cht c th gy d ng trc khi dng cho BN - Nu BN ngai tr nn gi li 30 pht sau khi tim cc thuc d gy shock phn v - Cn c thuc v phng tin cp cu sc phn v nu n xy ra - Gio dc BN nhng ngi mn cm vi nc c cn trng h c thc phng

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BI 13: CHM SC BN PH PHI CP 1. BN KH TH DO TRN DCH VO PH NANG: - T th BN: gip gim lu lng tim phi, gim tr phi: nhanh chng t BN t th ngi thng gc, hai chn, hai tay thng xung. Nu BN mt khng th t ngi nh trn c, c th t BN ngi ta vo tng, hai chn dui thng, tay bung thng - Ci thin h hp cho BN: cho BN th oxy qua ng thng mi hoc mt n 8 10l/p. Trng hp nng c suy h hp: tr gip BS t ni kh qun, th my - Garo 3 chi lun phin theo y lnh: c tc dng gim s tr v tim ca mu tnh mch, gi mu phi Bo cho BN bit mc ch garo o HA, bt mch trc khi garo c th so snh sau ny Ct garo: + Dng HA k: bm HA k n mc trn HA ti thiu 10mmHg + Dng dy garo: buc dy garo trn khn nh, lc xit va phi cn bt c mch quay v mch mu chn Bt u ct 3 chi gm cnh tay tri, i tri, i phi Ch : khng bt tt ng mch, garo ch c php cn tr tun hon tnh mch m thi Th garo 15 p/ln ( c th 5 10 p/ln i vi ngi ln tui v nhng BN suy gim tun hon ngn nga hoi t chi v cc tai bin khc ) Lun phin garo theo chiu kim ng h Theo di huyt p Khi nguy c ht, garo c b ra tng ci mt (15 pht b 1 ci ) - Theo di DSH 30 p/ln trong giai an cp, 3h/ln trong 24h sau - t ng thng tiu theo y lnh theo di lng nc tiu - Thc hin y lnh v thuc: Morphin lm gim trng thi ht hong lo lng, gim p lc mao mch phi, gim tnh thm thnh mchTrang 89

Li tiu lm gim khi lng tun hon, trinitrin ngm di li ( risordan ) gy gin tnh mch ngoi bin, lm gim dng mu v tim Aminophylin dn ph qun2. BN HT HONG LO S DO KH TH:

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D lun bn cnh BN ng vin gii thch v bnh cho BN D c thi bnh tnh nhanh nhn Lun quan tm n cn chm sc Bo v gii thch nhng vic sp lm Thuc an thn theo y lnh BI 14: CHM SC BN THIU MU

A. NH NGHA: Thiu mu l h/tng gim s lng hng cu hoc gim nng huyt cu t trong mu ngoi vi C th: + n Hematocrit (Hct) < 30%, Hemoglobin (Hb) < 10/100ml HC, HC < 3,5 triu/mm3 + nam: Hematocrit (Hct) < 36%, Hemoglobin (Hb) < 12/100ml HC, HC < 4 triu/ mm3 B. CHM SC: 1. DINH DNG KM DO RI LON TIU HA: - Ch n giu protein, nng lng, hoa qu, rau ti - Protein 1g 1,5g/kg c th - Glucid 65 70% tng calo - Vitamin: B6, B12, C - Calo: 2000 2500 calo/ngy - Thcn hp khu v gip BN n ngon, d tiu - Trnh cc cht kch thch, sinh hi, c nhiu gia v - Trnh to bn - Ch cung cp thc phm c nhiu cht st v vitamin B12 2. THIU KIN HC V BNH - Ch lm vic ngh ngi ng sau khi khi bnh - Ci thin ch n, a dng ha ba n, n nhiu loi thc n khc nhau nht l cc ngun thc n ng vt c nhiu st nh tht, gan, trng, tit canh, thc n giu vitamin C nh hoa qu - B sung vin st cho cc i tng c nguy c cao: Ph n la tui 13 tr ln cn c ung vin st d phng, mi tun ung 1 vin to ngun st d tr cho c th. Khi c thai cn kt hp n ung tt, ung vin st u n mi ngy 1 vin ( 60 mg ) trong sut thi gian mang thai cho ti sau khi sinh 1 thngTrang 90

B sung vin st cho tr em l cn thit, nhng cn c ch nh v theo y lnh ca BS - Tng cng st vo thc phm: hin nay nc ta ang nghin cu tng cng st vo thc n nh bnh bch quy, nc mm, nhm a 1 lng st va cho nhu cu qua nhng thc n ny - Phi hp vi cc chng trnh chm sc sc khe ban u, d phng chng nhim khun, v sinh mi trng, phng chng nhim giun. 3. GIM KH NNG HOT NG DO MT MI: - Cn c ngh ngi v ng y d tr nng lng - To mi trng yn tnh, thun tin BN c ngh ngi - Xen k ngh ngi cn tp luyn tng sc chu ng, hot ng tng dn, trnh gng sc - phng t ng do mt thng bng, yu mt, ngt - Khi thiu mu c iu tr cc xt nghim mu tr v bnh thng 4. GIM LU LNG TIM P NHANH: - Nhn ra cc nguyn nhn lm tng hi hp v kh th phng trnh cho n khi triu chng thiu mu c ci thin - Nu xut hin kh th: th oxy, nm u cao khi cn - Trnh gng sc khng cn thit - Truyn mu theo y lnh - Trnh truyn dch nhiu khi ph, suy tim - Trnh stress

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IU DNG NHIBI 1: NUI CON BNG SA M 1. LI CH CA VIC NUI CON BNG SA M Li ch i vi con: - Thnh phn dinh dng cn i, d hp thu v ph hp vi s pht trin ca tr - Phng chng nhm khun v trnh c cc bnh d ng - C gi tr tuyt i vi s thng minh ca tr - Tng thm tnh cm m v con Li ch i vi m: - T cung of m s c co sm nh cht Ocytocine v Prolactine cng tit ra nn m t mt mu sau sinh - Prolactine to ra c tc dng ngn cn s rng trng, gip b m chm c thai - M cho con b sm, cc ng dn sa ca tuyn v thng sm khng b tc nghn, khng gy Abces v - Tit kim c ngn qu gia nh - Khng mt thi gian chun b phng tin, dng c pha sa - gip rut tr thch nghi dn cc thnh phn ca sa m cng thay i v s lng v cht lng trong 2 tun u sau sinh v c gi theo th t sau: a. Sa non: - C t thng th 4 ca thi k mang thai v tn ti trong 6 ngy u sau sinh - C mu vng nht, c hn so vi sa vnh vin - C nhiu Protein, t Lactose v cht bo hn sa vnh vin - Sa non l thc n u tin ca tr s sinh v cc thnh phn ph hp vi nhu cu ban u - Giu nng lng gip tr chng c i rt - Giu cht dit khun nn gip tr trnh c cc bnh nhim trng tiu chy, vim phi, vim mng no - Nhiu vita A gp 10 ln so vi sa vnh vin - Ph hp vi hot ng cha tt ca thn trong nhng ngy u tin sau sinh v cha t Calci v Phospho hn so vi sa vnh vinTrang 92

b. Sa chuyn tip: C t ngy th 7 n 14 ngy

c. Sa vnh vin: - C t tun th 3 sa m s c c nh v cht lng cng nh s lng - M bnh thng khe mnh, lng sa tir ra trong 24h c th t n mc ti a l 1200ml - M sa cho con b 10 15 pht b s no v ng lin 3-4h sau mi thc dy i b. Mi ngy trong thng u tr tng cn t nht 25g, trung bnh 50g v nhiu nht l 100g - M thiu sa ch 1-2h sau l tr khc i b - D m thiu hay sa, tr phi c no sa m trong 6 thng u m bo s pht trin bnh thng cho tr v th cht v tinh thn - iu quan trng nht l khng cho tr n dm sa khc trong thi gian ny v c hi nhiu hn. Nu c sa nhn to th nn cho m ung c nhiu sa cho con b. Ngoi bin php tng s ln b trong ngy tng tit Prolactine gy to sa, nn cho m n cht v ung nc mi ngy 1500ml di nhiu dng: sa cc loi, nc ung, thc n lng, ch cho 2. CC YU T LM GIM TIT SA M: - Cho b chm sau sinh 2-3 ngy s lm hn ch s hot ng ca tuyn v v khng c cht Prolactine - M c bnh: suy tim, thiu mu, suy dinh dng - M qu tr < 18 tui, tuyn v cha trng thnh - M khng tng cn y khi mang thai ( 10-12kg) - M dng cc loi thuc c ch tuyn sa, thuc chng d ng, khng sinh - M lao ng nng, tiu hao nhiu nng lng, khng cn cho s tit sa - M bun phin lo u suy ngh s hn ch no tit cht Prolactine - Khong cch cho b qu di > 3h lm cho 2 v tc sa v ngng hot ng - Con trn 12 thng lng sa gim dn vi thi gian. Trong nm u sa m tit 1200ml/ ngy, nm th 2 cn 500ml/ngy, nm th 3 cn 200ml/ngy Ngoi ra cht lng sa cng gim nu m n ung qu king c do thiu cc cht: 1- Thiu st: Nu m thiu mu hoc n king cc cht giu st nh tht, lng trng, rau, tri cy 2- Thiu vita B1: Do m n cm qu trng vi c hay tht kho mn khng n rau v tri cy 3- Thiu vta A, D, E, K: Nu m king n du m 4- Thiu calci, phosphore: Nu m king n tm, cua, s - M n 1 s gia v c mi cng lm cho sa c mi ( hnh, tiu, t, ti) c th lm tr khng b - M tip xc vi cht c: Thuc tr su, ru, hi ch cc cht ny t mu m vo sa m c th gy ng c cho con 3BO V NGUN SA M: Chm sc hai bu v m - Ngay khi mang thai ngi m phi kim tra 2 bu v: nu bu v tt vo th hng ngy phi lau ra, xoa bp v ko ra - V sinh bu v sch s trc v sau khi cho con b bng nc m, khng ra bu v = cn, x phng.Trang 93

- Khng nn nt v qu cht - Khi u v b nt nn bi vaselin - Khi v b p se khng cho tr b: phi vt sa hoc bm ht hng ngy m bo cht cho ngi m khi mang thai v cho con b - n ung cht, thc n giu cht dinh dng - Trong thi gian mang thai phi tng c t 10- 12kg - Sau sinh khng c king khem qu mc m phi n ung y cht dinh dng Lao ng hp l - Gia nh v c quan nn to iu kin cho ngi m mang thai v cho con b lao ng ph hp, c thi gian v cho con b, khng nn lm vic qu sc nh hng n s bi tit ca sa - Cho con b u n hng ngy, nu i lm xa, i cng tc khng cho con b c th phi vt ht sa, trnh ng gy tc sa - Trong t/gian cho con b ngi m phi lun gi v sinh, phng nhim khun v khng dng thuc ty tin Cch cho con b: - Cho tr b m cng sm cng tt, ngay sau sinh trong vng na gi u - Khi cho tr b phi: + Lau sch u v trc khi cho tr b + B tr nm t th thoi mi + u v thn trr nm trn mt ng thng + Mt tr quay vo v, ming i din vi nm v + Ngi m ngi b st tr cho b: tr s sinh phi u v mng, ch nn cho con nm b khi m mt + M nng v = tay a v vo ming tr. Thnh thong nn dng ngn tay ci v tay tr nng v n nh vo v trnh trnh v bt vo mi tr, gip tr ngm v b tt hn - Nhng du hiu chng t ngm bt v tt: + Ming m rng, ngm su vo qung v + Mi di hng ra ngoi + Li chm quanh u v + M chm trn + Tr mt chm, su, c nhp ngh khi nut + C th nhn hoc nghe thy tr nut - Cho tr b ht v bn ny ri ti bn kia - Khi cho tr b xong nn vt sa cn li trong bu v - Thi gian mi ln b: t 15-20pht. Khng nn cho tr b qu lu lm mt sc ca tr - Sau khi cho tr b xong cn b tr t th u cao trong vng 5-10pht tr c th hi, trnh nn tr - Cho tr b theo nhu cu ( k c ban m ). Nu tr khng b c th vt sa cho ung = mung - Cho tr b ko di n 18-24 thng tui. khng nn cai sa trc 12 thngTrang 94

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BI 2: DT SA V N DM 1NGUYN TC DT SA: Tp cho tr n t thng th 6, khng ch n hn 6 thng tr d tip thu. Cho tr n thm nu thy tr: + Vn cn i sau mi c b m + Khng tng cn bnh thng Khi u n t t n nhiu, t lng n c dn, t mm n cng Tp cho tr n mi thc n ca ngi ln Ch thay i mn n, mu sc, ch bin hp khu v tr thm nHng ngy nn m bo 4 nhm thc n, khng cn nhiu nhng ngy no cng c Cng thc n b sung gim dn s ln b ca tr trong ngy cho n lc dt sa hn 18-24 thng ty theo kh nng tit sa ca m 2- CCH S DNG CC CHT: Tri cy: bt u ung tri cy di dng nc mi ngy khong 1-2 mung caf, sau tng dn s lng. T thng th 6 c th cho tr n c ci nh chui chin, u Bt: cho tr n t thng th 6, ch cho tr n bt t thng th 5 khi m khng sa m, lc tr c men Amylase tiu ha cht bt Chn bt u tin phi long 5%: 2 mung caf bt trong 200ml nc + Nm mn: bng nc mm + Ch cn 1 ln trong ngy + C th pha bt bng nc rau, nc tht, sa b T 8-9 thng: 2 chn bt /ngy, bt c 10% ( c nh h ): 4 mung caf bt trong 200ml nc, trong mi chn bt phi c 4 nhm cht ( bt, m, rau, du ) T 10-12 thng: 3 chn bt hoc cho/ngy T 1-2 tui nn thay bt bng cho c: 4 chn/ngy Trn 2 tui nn thay cho bng cm, ngy 4 chn chia 3 ba Cht m: tr cn c m ng vt v m thc vt + C th tp cho tr n tht, trng, c, sa t thng th 6. Tm cua t thng th 9 + S lng tng dn theo tui Cht rau: rt cn cung cp cht st, cc loi mui khong, vitamin v cht x + Thng th 6: tp ung nc rau, n rau luc nghin nh khi tr mc rng + Trn 1 tui: n rau xo, luc, nu canh, thi nhTrang 95

- Du m: l ngun cung cp nng lng ch yu, c trong cc loi du thc vt, m ng vt,

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v b. Cc loi du thc vt c gi tr dinh dng cao v cha nhiu acid bo khng no, tan trong nhit thp, ha tan nhiu vitamin A, D v d hp thu. Do , trong mi chn bt hoc cho ca tr nn cho 1 mung caf ( 5g ) du phng, m, oliu 3CH N CHO TR T 0-3 TUI: 0-6 thng: b m hon ton 6 thng: b m+nc tri cy 1-2 mung caf+1 chn bt long 7 thng: b m+nc tri cy 2-4 mung caf+ 1 chn bt c 8-9 thng: b m+1/4 tri chui chin+2 chn bt c 10%( bt+tht+rau+du ) 10-12 thng: b m+1/2 tri chui chin+3-4 chn bt/cho c 1-2 tui: b m+1 tri chui chin+4 chn cho c 2-3 tui: 4 chn cm chia lm 4 ba+ tri cy

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BI 3: CHM SC TR NHIM KHUN H HP CP ANHN NH: 1- HI THN NHN V BNH NHI: Cc du hiu nguy him ton thn: - Khng ung (b) c - Nn tt c mi th - Co git - Ng li b, kh nh thc Cc du hiu khc: - Tui, cn nng? Thi gian khi bnh? Triu chng: st, ho, s mi, ri lon tiu ha + Tr c ho, s mi khng? Ho bao lu ri? Tnh cht ho? Ho khan hay ho c m? + Ho nhiu vo ban ngy hay ban m? + Tr c kh kh? Tnh cht cn kh kh? + Tr c st khng? St t bao gi? C co git khng? + Tr c au tai, chy m tai khng? Chy m bao lu ri? + Tr c au hng khng? Thi gian au lu cha? + Tr c nn i, au bng, tiu chy? - Tr c dng thuc g cha? Tin s d ng thuc 2-CN PHI NHN NH KHI TR NM YN - Xem tr c ng li b hay khng? - Du hiu co rt lng ngc: nhn vo ranh gii gia ngc v bng thy rt lm khi tr ht vo - Quan st du hiu tm ti mi, quanh mi - Suy dinh dng th ph hoc teo t - Du hiu th nhanh bng cch m nhp th/ 1pht. Tr c gi l th nhanh khi nhp th trong 1 pht: + Tr < 2 thng: 60 l/pht + Tr 2 12 thng: 50 l/pht + Tr 12 - 5 tui : 40 l/pht - Ting th rt pht ra khi tr ht vo - Ting kh kh khi tr th ra - m mch trn 1 pht, khi tr ng hoc nm yn. Giai on u khi tr st, mch thng nhanh, mch ca tr trong 1 pht gi l nhanh khi: + Tr < 2 thng: 150 l/pht + Tr 2 12 thng: 140 l/pht + Tr 12 5 tui: 120 l/phtTrang 97

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Suy h hp giai on mun mch s chm o nhit : st? h thn nhit? Nhn tai xem c chy m tai khng? n vo c au khng? BCAN THIP IU DNG: 1- Tr ho v kh kh do tng tit v ng cht tit: Mc tiu: tr thng ng th hiu qu, gim ho v kh kh Cho tr nm phng thong mt trnh gi la. Loi b tt c nhng g lm cn tr h hp. T th tr nm u cao, mt nghing qua 1 bn Ht m nht mi ming, a ng vo nh nhng trnh lm try xc nim mc gy chy mu Trng hp mi tr b kh cng gy nght th nh 1-2 git nc mui sinh l 0.9% lm long dch Thc hin cc thuc gim ho v lm du hng: siro Perctol, siro Astex Thc hin thuc dn ph qun khi c kh kh nhiu: Ventolin ( ung, phun kh dung ) Cho tr ung nhu nc: nc cam, chanh, nc m Lng gi: Tr gim ho Th m m long 2Tr th nhanh, co lm ngc Mc tiu: Tr khng cn du hiu co lm ngc, ht th nhanh Cho th oxy khi: + Tr tm ti hoc SaO2 < 90% hay PaO2 < 60 mmHg + Th co lm ngc nng, th qu nhanh iu chnh liu kng oxy theo ng y lnh: + Canula: tr nh: o.5 3 l/pht - tr ln: 1 6 l/pht + Mask: c hoc khng c ti d tr: 6 8 l/pht Theo di SaO2, DSH ch nhp th, tnh cht th, ting th nght m thng ng th kp thi Theo di mu sc da, nim mc Cho tr th NCPAP ( nu c ch nh ) V sinh mi sch s Theo di h thng oxy Thc hin thuc dn ph qun theo y lnh ( phun kh dung/ung ) Chun b v ph gip t ni kh qun khi tht bi vi oxygen hoc NCPAP Lng gi: Nhp th trong gii hn bnh thng - Mi hng - SaO2 t: 92 96%

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3- Dinh dng km do chn n Mc tiu: Tr c cung cp y cht dinh dng - Tr b m cho tr b bnh thng. Trng tr khng b c th vt ly sa cho tr ung bng mungTrang 98

- Tr b sa b th pha bnh thng ngoi c b cho tr ung thm 100 200 ml nc chn - Tr n c nn khuyn khch, ch n bnh thng khng king c - Tng khu phn v s ln b (n), sau khi khi bnh vn duy tr them 1ba n mi ngy cho n khi cn nng tr tr v bnh thng nh lc ban u - Ung nhiu nc m, cam, chanh sung vitamin C v b lng mt ncqua st v th nhanh - Tr qu nng khng n c = ng ming: cho n qua ng thng mi d dy. Nng lng cn tng them 30- 50% b tr tng cng h hp, trnh kit sc - Nui dng qua ng tnh mch: tim truyn theo y lnh - Theo di cn nng, kh nng tiu ha ca tr - Lng gi: Tr khng st cn n ngon ming Ung nhiu nc

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BI 4: CHNG TRNH TIM CHNG 1- LCH TIM CHNG M RNG TI VIT NAM:

LAO: S sinh BH UV HG : 2 3 4 thng, nhc li 18 thng hoc ( 12- 23 thng ) BI LIT: 2 3 4 thng v 18 thng, nhc li sau 30 thng hoc ( 24 35 thng ) SI: sau 9 thng VGSV B: s sinh, 2, 4 thng Cc loi Vaccin ngoi tim chng m rng a/ Vim gan siu vi A

- Ch nh: bt u chch nga di 2 tui + Cc trng hp c bnh gan mn tnh + 2 tun trc khi n vng dch t vim gan A - Mt liu c kh nng min dch 95%, 2 liu cch nhau 1 thng min dch 100% b/ No m cu A, C - Kh nng to min dch km tr < 2 tui ( ch 40% c khng th sau chch nga ) - Cch tim chng: + Ngi ln, tr > 4 tui nhc li sau 5 nm + Tr di 4 tui nhc li sau 1 nm do p ng min dch km c/ Vim no Nht Bn - Chng 2 liu cch nhau 1 tun phng nga c khong 80% - Nu n vng dch t cn tim liu th 2 trc khi n vng dch t 10 ngyTrang 100

2- THC HIN TIM CHNG: Chun b cho bui tim chng

- Ghi vo s tim chng tt c tr em mi sinh, tr < 1 tui - D tr kinh ph, vt t v dng c tim chng- Thng bo cho cc b m c con cn tim chng v ngy gi, a im tim chng

- Nhn Vaccin ngay trc bui tim, bo qun ng cc Vaccin - Tit khun trc cc dng c cn cho tim chng Tin hnh tim chng

- m bo v khun- m bo hiu lc ca Vaccin: Gi lnh Vaccin khi vn chuyn n ni tim v trong sut

bui tim - m bo ng k thut tim chng + Tim BCG: 0,1ml tim trong da vo cnh tay tri, sau tim 2 3 tun s hnh thnh so, nu cha c so phi tim li khi tr cn < 1 tui + Tim BH UV HG: 0,5 ml vo bp i, tim 3 mi, mi mi cch nhau t nht 1 thng. Nu tr co git th khng tim na + Tim Vaccin si: 0,5 ml tim di da cnh tay + Ung Vaccin sabin: mi ln 3 git, ung 3 ln, khong cch gia cc ln t nht 1 thng Gio dc y t v tim chng

- Gio dc b m v li ch tim chng, cc bnh cn tim chng v cc phn ng ph c th xy ra - Nhc b m a con tim li trong nhng ln sau - Gii p cc thc mc ca b m sau khi tim chng Kt thc bui tim chng

- Hon thnh vic vo s tim chng- nh gi sau bui tim v bo co kt qa tim chng hng thng 3- CC TAI BIN V PHN NG PH SAU KHI TIM CHNG:

1/Tim BCG:Trang 101

- Phn ng thng thng: Khong 2 tun sau khi tim, ch tim c 1 nt hi sng, ng

knh khong 10mm. T 2 3 tun sau tr thnh p xe nh ri lot ra v t lnh li so c ng knh khong 5mm. y l phn ng tt, v phi kim tra so ln tim sau, nu khng c phi tim li- Phn ng mnh: p xe su hn, sng hch nch hoc gn khuu tay

Ngyn nhn:

+ Khng m bo v trng + Tim sai k thut: tim di da qa su + Tim lng Vaccin nhiu hn quy nh

X tr:

+ Nu ch c phn ng ti ch: khng cn iu tr g + Nu lot to, hch sng to, chuyn ngay ti bnh vin- Phn ng nhanh: xut hin sng ngay sau khi tim cha c 2 tun

+ Tr tim BCG + Tr nhim lao

Ngyn nhn:

X tr:

+ Nu do tr tim lao: khng cn x tr g + Nu nghi tr nhim lao: chuyn tr i khm ngay 2/ Khi ung Vaccin Sabin: Thng thng khng c phn ng g, nu tr ang tiu chy th tc dng s km hn, khi cn cho tr ung b sung 1 liu na sau 1 thng 3/ Khi tim Vaccin BH UV HG- St: mt s tr st vo chiu ti sau khi tim, st s ht ngay trong vng 1 ngy - Ti ch: au, sng, , tr quy khc hn thng ngy

X tr: Thng bo cho b m bit cc triu chng, khng cn iu tr g, cc triu chng s ht sau 1- 2 ngy, nu st cao c th ung paracentamolTrang 102

- p xe: au v sng ngay ti ch tim sau 1 tn hoc hn

Nguyn nhn: + Khng m bo v trng + Tim sai k thut: tim qa su

+ Chm nng

X tr:

+ Khng sinh nu cn + Nu khng ht phi chuyn n bnh vin chc tho m 4/ Khi tim Vaccin Si: St v ni ban: Tr c th st t 1- 3 ngy sau khi tim, i c ni ban nh si nh X tr: Ni cho b m bit rng cc triu chng ny nh hn nhiu khi b mc bnh si, cho ung paracentamol nu st cao 4/ BO QUN VACCIN DY CHUYN LNH V CCH S DNG PHCH GI LNH VACCIN: Bo qun Vaccin

- Vaccin d b ph hy nhit cao, ha cht - Vaccin BH UV HG d b ng bng v h hng nu nhit bo qun < 0 C -> Bo qun tt nht nhit 0 8 C Dy chuyn lnh

- Vaccine c bo qun trong sut thi gian vn chuyn cho n khi tim cho BN -> dy chuyn lnh S dng phch lnh bo qun Vaccin

- Gi lnh trong khi vn chuyn: + Kim tra phch c rain nt khng, np c kht khng - Kim tra xem nhit bnh tch lnh tuyn di ( huyn, trm y t ) c nhit 0 khng? + Khng Vaccin BH UV HG tip xc st bnh tch lnh hoc lnh: c th bc giy bo cc l Vaccin ny + Lnh Vaccin sm trnh nng khi vn chuynTrang 103

+ Trng hp khng c bnh tch lnh th thay bng 1,5kg: phi bc nc trong ti nilon trnh lm t v h nhn Vaccin - Gi lnh trong sut bui tim chng: + Ch m phch khi cn sau y kn ngay + c nhit k t nht 2 ln: lc bt u tim v kt thc bui tim + Cc l Vaccin m phi t vo cc nc lnh hoc trn 1 bnh tch lnh

BI 5: CHM SC TR TIU CHY QUY TRNH CHM SC: A/ NHN NH: 1- Hi: - B c b tiu chy khng? ( tiu chy l i tiu phn lng khng ng khun > 3 ln/ngy) - i tiu my ln/ngy? - Phn nh th no? Ln nhy mu? - Tiu phn lng bao lu ri? - Trc khi tiu chy tr n g? - C au bng khng? - C i tiu c khng? S lng, mu sc nc tiuTrang 104

- C nn khng? - C st khng nhit ? - C ung thuc g? 2- Thm khm: nh gi mc mt nc L bc tip theo of vic nhn nh tr TC.Ty theo m/ nng nh of TC c chia thnh 3 loi mt nc: Khng mt nc hay cn gi l mt nc A: - Lng nc mt c tnh khong di 5% trng lng c th lc tr khe mnh trc C mt nc hay mt nc B: - Mt nc nh: lng nc mt lc ny khong 5 10% trng lng c th tr lc khe mnh Mt nc nng hay mt nc C: - Lng nc mt lc ny khong 10% trng lng c th lc khe mnh - Da nim: + Mu sc: ti? + Tnh cht: kh, lnh, ph? + n hi da: chm > 2 giy? + Thi gian y mao mch > 2 giy? - Du sinh hiu: + Mch: nhanh? + Nhit : tng? + Nhp th: tng? + Huyt p: gim? - Cn