Article 126 Nursing Care for Obese Patients with Paralysis, Bedsores, High Fever, and Shock

(1) Prevent bedsores: Frequently turn over and passively move the limbs to avoid local pressure that could lead to impaired blood circulation.

(2) Prevention of urinary tract infection: Obese individuals should clean the urinary tract promptly after urination and defecation and keep it dry. For those with difficulty urinating, massage the bladder regularly, but do not apply heavy pressure. When the condition permits, assist the patient to get out of bed and move around early to promote emptying of the bladder of residual urine.

(3) Prevention of pneumonia: Keep warm and avoid getting cold. Obese patients should do deep breathing exercises regularly every day and consciously cough and expectorate to keep the airway clear.

(4) Prevention of flatulence and constipation: Patients should eat more vegetables and fruits and less gas-producing foods. When constipated, they should take a mild laxative or have an enema every 2-3 days. Abdominal massage or acupuncture can also be performed. If necessary, the stool can be removed by hand.

(5) Prevention of falls, burns, and frostbite: Bed rails should be added if the patient is unconscious. When using a hot water bottle, the water temperature should be <50℃, and a cloth cover should be used to prevent direct contact with the skin. The location should be changed frequently. Care should be taken to prevent burns during physiotherapy, acupuncture, or cupping. Limbs should be kept warm in cold weather.

(6) Prevent limb deformities and contractures and promote functional recovery: Paralyzed limbs should be kept in a functional position; prevent foot drop by using a foot brace or a pillow to support the soles of the feet; massage the limbs twice a day and perform passive exercises.

(7) Psychological adjustment and precautions during rehabilitation: ① Obese patients who have been in a coma due to intracranial disease may still have hemiplegia or speech impairment after awakening. Family members should continue to provide daily care to prevent bedsores and lung infections. At the same time, patients should strengthen active limb movement and speech training, which can be combined with acupuncture and physical therapy. ② Ensure adequate nutrition. Eat regularly, in small, frequent meals, and avoid overeating. Avoid spicy and irritating foods. ③ For patients with cerebral hemorrhage, pay attention to blood pressure and take appropriate antihypertensive drugs; maintain emotional stability and avoid sadness or excitement; keep bowel movements regular, and use mild laxatives if necessary to avoid straining during defecation, which could increase intracranial pressure and cause another cerebral hemorrhage. If headache, vomiting, or seizures occur, seek medical attention promptly. ④ For obese patients with behavioral disorders, family members and medical staff should help analyze and understand the pathology and promote the recovery of self-awareness. Provide patients with various forms of support, including psychological support, to help them pay attention to the balance between work and rest, stimulate positive emotions, treat the primary disease, and take medication diligently.

(1) Prevention of pressure ulcers: Prevention of pressure ulcers requires adherence to the "seven diligences": frequent turning, frequent washing, frequent massage, frequent changing of clothes, frequent tidying, frequent checks, and frequent handover. "Two maintenances": keep the mattress flat and dry; keep the skin clean and dry. "One avoidance": avoid dragging, pulling, pushing, and rubbing. For elderly, obese, long-term bedridden, paralyzed, and patients unable to turn over automatically, pay attention to changing their position regularly (turning them over every 2-3 hours), and apply 2.5% iodine tincture to bony prominences under pressure twice daily. Alternatively, massage with safflower alcohol or 50% alcohol twice daily, and use air rings or soft pads to prevent pressure. If the skin is dry, apply a small amount of lubricant to prevent dryness and cracking. When changing positions and handling bedpans, move gently to prevent skin damage.

(2) Timely treatment of existing pressure sores: ① For any area with redness, swelling, blisters, or sores, change the patient's position regularly. If the patient's condition does not allow for changing position, an air mattress can be used, or an air ring or a perforated bed board or mattress can be used to reduce pressure. ② For local redness and swelling, apply 2.5% iodine tincture topically. Alternatively, apply a wet compress of 50% magnesium sulfate solution or 75% alcohol to promote absorption and dissipation, and increase the frequency of turning over as needed. ③ For blisters, under aseptic conditions, use a syringe to aspirate the exudate from the blisters, then apply a disinfectant such as 0.1% chlorhexidine, 1% neomycin, or safflower oil, cover with sterile gauze, apply a pressure bandage, or secure with a bandage. ④ For fresh, uninfected sores, apply appropriate antibiotic solutions or traditional Chinese medicine such as pearl powder, tin powder, or collagen several times a day. If there is discharge, it should be sent for bacterial culture and drug sensitivity testing to select appropriate anti-infective drugs and keep the wound clean. ⑤ For large and infected wounds, use a wet compress with a solution of oxytetracycline or other antibacterial solutions to clean the wound, then bandage with 5% methaqualone or petroleum jelly gauze. Change the dressing at least once a day. For edematous granulation tissue, use a wet compress with 3% hypertonic saline or 50% magnesium sulfate solution 2-3 times a day. For poor granulation tissue growth, use a wet compress with warm saline gauze, or apply glucose powder, petroleum jelly gauze, or a tissue-regenerating powder to promote granulation tissue growth. When there is a lot of discharge from the wound, petroleum jelly ointment should not be used to avoid hindering the drainage of pus. If there is a fungal infection, it must be treated with clotrimazole, nystatin, and alkaline solutions. If there is excessive or uneven granulation tissue, it must be trimmed, cleaned, and treated with medication. ⑥ The wound can be treated with infrared radiation or a heat lamp 2-3 times a day for 10-15 minutes each time. Laser treatment can also be used. Adjust the distance during irradiation to prevent burns.

(3) Issues to be aware of during rehabilitation: Patients should build confidence and actively cooperate with treatment. Pay attention to keeping the affected area and the area around the new granulation tissue clean and dry, and avoid contamination, sweating, pressure and further injury.

(1) The diet should be light and easily digestible, consisting of soft, high-vitamin, high-protein, low-fat liquid or semi-liquid foods. Drink plenty of water, with a daily fluid intake of no less than 3000 ml, and eat plenty of fresh fruits and vegetables. Record intake and output as necessary.

(2) For patients with a body temperature above 39℃ or accompanied by febrile crisis, close observation of body temperature, pulse, respiration, blood pressure, changes in mental status, fever pattern, characteristics, and accompanying symptoms is necessary, along with physical cooling methods. Options include ice packs, ice caps, cold compresses, alcohol rubs, cold water rubs, warm water rubs, ice water enemas, and acupuncture at points such as Hegu, Quchi, and Dazhui. Obese individuals with high fever are prone to dehydration due to their thick fat layer and low body water content; therefore, antipyretics should be used with caution. Fluids should be replenished promptly during profuse sweating to prevent collapse or shock, especially in elderly or weak patients. Pay attention to whether the patient experiences collapse during profuse sweating or fever reduction, and whether other symptoms such as chills, profuse sweating, cough, vomiting, diarrhea, rash, or bleeding occur to assist the doctor in making a definitive diagnosis. Monitor peripheral circulation; high fever accompanied by cold extremities and cyanosis often indicates a more serious condition. If the body temperature decreases, the extremities warm up, and the cyanosis lessens or disappears after treatment, it indicates that the treatment is effective.

(3) Nursing care for febrile seizures. Patients with febrile seizures should be protected by bed rails to prevent falls and injuries. To prevent tongue biting, a mouth opener and tongue clamp should be kept at the bedside. Nasopharyngeal secretions should be suctioned promptly to maintain a clear airway.

(4) Oral care. Oral care should be performed every morning and evening, and the mouth should be rinsed before and after meals. For dry lips, liquid paraffin can be applied, and for those with herpes, antibiotics or antiviral ointments can be used. Oral care should be especially emphasized for patients with high fever and coma to prevent infection and mucosal ulceration.

(5) Skin care. For patients with high fever who sweat profusely during the cooling process, their clothes and bedding should be changed promptly. Pay attention to skin hygiene and ensure the bed sheets are comfortable and dry. For patients with bleeding tendencies, prevent pressure and skin damage.

(6) Keep the indoor air fresh.

(7) Patients should take the initiative to adjust their own psychology and actively cooperate with the treatment to shorten the course of the disease.

(1) Patients in severe shock should be placed in the intensive care unit for monitoring and treatment. The room temperature should be 22-28℃, the humidity should be around 70%, and the ventilation and air should be fresh.

(2) Pay attention to keeping warm, and cover with cotton quilts or blankets as appropriate. Use physical cooling methods for patients with high fever.

(3) Keep the patient calm and prevent accidental injury. Due to the hypoxic stress response, the sympathetic nervous system is excited and the secretion of catecholamines increases. In the early stage of shock, the patient is in an excited and agitated state and often does not cooperate with treatment. Therefore, the limb receiving intravenous fluids should be properly secured and bed rails should be added to prevent the patient from falling. If the patient is extremely agitated, sedatives such as diazepam can be used.

(4) Closely monitor the dynamic changes in vital signs such as blood pressure. Blood pressure is often an important indicator of the degree of shock. However, in the early stages of shock, the sympathetic nervous system is excited, and blood pressure may not only fail to decrease but may even increase. At this time, antihypertensive drugs such as reserpine should never be used, otherwise it will cause serious adverse consequences. Pay attention to the issue of measuring blood pressure in particularly obese patients, that is, the blood pressure measured by the commonly used wide cuff is relatively higher than the actual blood pressure.

(5) Vasoactive drugs should be used as early as possible after blood volume is replenished to improve pulse pressure and microcirculation, but blood pressure and urine output must be closely monitored.

(6) Supplement energy appropriately to avoid ketoacidosis caused by rapid and large-scale fat decomposition, which may further aggravate shock.

(7) Closely monitor blood pressure, electrocardiogram, respiration, urine output, urine specific gravity, pH, consciousness and blood gas changes, etc., in order to understand the functional status of important organs and changes in metabolism in the body, so as to detect, treat and correct them early.

(8) In order to ensure smooth fluid infusion, it is now generally recommended to place a deep vein catheter.