Nursing Considerations for Patients Receiving Salicylates 水杨酸盐类药使用患者的护理考虑
Assessment: History and Examination
评估：病史和检查
• Assess for contraindications or cautions: history of allergy to any salicylate or tartrazine to avoid hypersensitivity reactions; renal disease because these drugs are excreted through the urine; bleeding disorders because of the drug effects on blood clotting; chickenpox or influenza in children to avoid the risk of Reye syndrome; and pregnancy or lactation to avoid adverse effects on the fetus or baby and risk of bleeding in the mother.
• Perform physical assessment to establish baseline status before beginning therapy and to monitor for any potential adverse effects.
开始疗法前先行体格检查，确立基线情况；监测有无任何潜在的不良效应。
• Assess for the presence of any skin lesions to monitor for dermatological effects.
评估有无任何皮肤损伤，监测有无皮肤病学效应。
• Monitor temperature to evaluate the drug’s effectiveness in lowering temperature.
监测体温，评价药物的降温效果。
• Evaluate central nervous system (CNS) status—orientation, reflexes, eighth cranial nerve function, and affect—to assess CNS effects of the drug.
评价中枢神经系统（CNS）状况：定向力、反射、第VIII颅神经功能、易感性—评估药物CNS效应。
• Monitor pulse, blood pressure, and perfusion to assess for bleeding effects of cardiovascular effects of the drug.
监测脉搏、血压、和灌注情况，评估有无药物对心血管系统产生出血效应。
• Evaluate respirations and adventitious sounds to detect hypersensitivity reactions.
评价呼吸和附加音，发现超敏反应。
• Perform a liver evaluation and monitor bowel sounds to detect hypersensitivity reactions, bleeding, and gastrointestinal (GI) effects of the drug.
行肝功能检查，监测肠鸣音，发现药物的超敏反应、出血和GI效应。
• Monitor laboratory tests for complete blood count (CBC), liver and renal function tests, urinalysis, stool guaiac, and clotting times to detect bleeding or other adverse effects of the drug and changes in function that could interfere with drug metabolism and excretion.
检查实验室值：全血细胞计数（CBC）；肝肾功能试验；尿分析；粪便潜血试验；凝血时间，以发现药物的出血或其他不良效应，可能影响药物代谢和排泄的功能变化。
Nursing Diagnoses
护理诊断
Nursing diagnoses related to drug therapy might include the following:
与药物疗法相关的护理诊断可能包括：
• Acute Pain related to CNS and gastrointestinal GI effects.
急性疼痛，与CNS和胃肠道GI效应相关
• Ineffective Breathing Pattern if toxic effects occur.
呼吸形态无效，发生毒性效应时
• Disturbed Sensory Perception (Auditory, Kinesthetic) if toxic effects occur.
感官知觉障碍（听觉、动觉），发生毒性效应时
• Deficient Knowledge regarding drug therapy.
知识缺乏，与药物疗法相关
Implementation With Rationale
实施与说明
• Administer with food if GI upset is severe; provide small, frequent meals to alleviate GI effects.
若GI不适严重，可与食物同服；少量多餐以减轻GI效应
• Administer drug as indicated; check all drugs being taken for possible salicylate ingredients; monitor dose to avoid toxic levels.
需要时用药；检查服用的所有药物是否含有水杨酸盐成份；检查剂量，避免毒性浓度
• Monitor for severe reactions to avoid problems and provide emergency procedures (gastric lavage, induction of vomiting, administration of charcoal) if they occur.
监视有无严重反应，避免问题；一旦发生，提供应急程序（胃灌洗、催吐、口服活性炭）
• Arrange for supportive care and comfort measures (rest, environmental control) to decrease body temperature or to alleviate inflammation.
安排支持性护理和舒适措施（休息、环境控制），降低体温或减轻炎症
• Ensure that the patient is well hydrated during therapy to decrease the risk of toxicity.
确保治疗期间患者体内水分充足，减少中毒危险
• Provide thorough patient teaching, including measures to avoid adverse effects and warning signs of problems, as well as proper administration, to increase knowledge about drug therapy and to increase compliance with the drug regimen.
充分教育患者，包括采取措施避免不良效应和问题的警示体征，以及正确用药，以增加药物疗法知识，增强用药顺从性
• Offer support and encouragement to deal with the drug regimen.
提供支持和鼓励，正确用药
Evaluation
评价
• Monitor patient response to the drug (improvement in condition being treated, relief of signs and symptoms of inflammation).
监视患者的药物反应（所治疾病的改善和炎症体征症状的缓解）
• Monitor for adverse effects (GI upset, CNS changes, bleeding).
监视有无不良效应（GI不适、CNS变化、出血）
• Evaluate the effectiveness of the teaching plan (patient can name drug, dosage, adverse effects to watch for, specific measures to avoid adverse effects).
评价宣教计划效果（患者可以说出药名、剂量、需要注意的不良效应、避免不良效应的具体措施）
• Monitor the effectiveness of comfort measures and compliance with the drug regimen.
监视舒适措施效果和用药顺从性
★Vocabulary for Today ★
Reye syndrome – 瑞氏综合征，急性脑病综合征
kinesthetic – a. 肌肉运动知觉的
lavage – n. 灌洗
gastric lavage --胃灌洗
induction of vomiting --催吐
charcoal – n. 活性炭
★Video ★
Aspirin
★Test ★
1. A 6-year-old boy cuts his hand on the training wheel of his bicycle. The wound is 1.5 cm in size and the bleeding stops with direct pressure. One of the steps of blood clotting involved platelet aggregation through activation of collagen. Platelet release of granules is mediated by the release of mediators. Which of the following mediators, if activated, will likely cause bleedingto continue?
A. Adenosine diphosphate
B. Dopamine
C. Serotonin
D. Thrombin 2. A 33-year-old woman who is 20 weeks pregnant with a porcine heart valve is at risk for thromboembolism. Which of the following is the best agent to use in this situation?
A. Heparin
B. Streptokinase
C. TED stockings
D. Warfarin sodium
答案 Key to Questions
1. B: Dopamine.
Dopamine release will unlikely stimulate platelet aggregation and will lead to continuous bleeding. Receptors on the surface of the adhering platelets are activated by the collagen of the underlying connective tissue. This causes morphologic changes in platelets and the release of platelet granules containing chemical mediators, such as adenosine diphosphate (ADP), thromboxane A2, serotonin, platelet- activation factor, and thrombin.
2. A: Heparin.
Heparin is the anticoagulant of choice for treating pregnant women with prosthetic heart valves or venous thromboembolism because this agent does not cross the placenta. Heparin has a rapid onset of action.
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