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病例分析要求:注明病例中的精神症状 ( 请在精神检查中用划线的方法具体注明) ,说明疾病诊断, 4 条护理诊断与相关因素,主要护理的措施。

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正确答案:

(1) 精神症状:①意志活动缺乏。②情感淡漠。③思维破裂。④意向倒错。⑤情感活动不协调。⑥思维破裂。⑦思维松弛。 -

(2) 疾病诊断:精神分裂症青春型。

(3) 护理诊断:

①有暴力行为的危险对自己或他人。 相关因素:精神活动处于兴奋状态,行为控制能力下降。

②不合作拒绝治疗护理。相关因素:认知障碍——幻觉、妄想。

③思维过程改变相关因素:认知过程和活动受到干扰。

④部分自理能力缺陷沐浴/卫生、穿着/修饰。相关因素: a.思维过程改变,不修边幅; b.行为紊乱、兴奋不合作。

(4) 护理措施:

①基础护理: a.做好人院评估。 b.提供安全和安静的环境。 C.维持正常的营养代谢。 d.帮助病人建立自理模式。 e.创造良好的睡眠环境。£做好排泄护理。

②症状护理:青春型病人临床以不协调性精神运动性兴奋为主要表现,如冲动、伤人、毁物,生活不能自理等。护士要掌握病情变化,不激惹病人,运用良好的语言有效地阻止病人伤人及破坏性行为, 必要时采取约束方法, 帮助病人控制冲动行为,同时协助病人做好基础护理。

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