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新生儿气胸护理查房课件_1

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With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 新生儿气胸护理查房 新生儿病房 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 案例导入 病史:39床,郭X之子,胎龄37+3周,出生体重2.75kg,因19小时 前出现呼吸急促,伴有呻吟,口吐泡沫,皮肤稍青紫,给予箱式吸 氧,药物治疗后皮肤转为红润 ,呻吟减轻,3小时前患儿突然氧合 不稳,出现呼吸困难及皮肤青紫加重,当地医院胸部ct回示存在气 胸,以’新生儿气胸’收入院。 体格检查 :患儿刺激反应稍差,哭声微弱,呼吸稍促,伴有呻吟 及口吐泡沫,口周稍青紫,三凹征弱阳性,全身青紫,双肺呼吸音 不对称,右侧偏低。查体T36.5C,P142次/分,R54次/分。 血气分析:PH:7.39,PCO2:37mmHg,PO2;44mmHg, Lac:3.1mmol/L. 入院后处理:给予暖箱护理,及时吸净口鼻分泌物,保持呼吸道 通畅,禁食,静脉营养液营养支持治疗。无创呼吸机辅助通气,抗 感染,营养脑细 胞等治疗。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 病程 3.24 15:43 患儿在无创呼吸机辅助通气下经皮血氧饱和度波动 在90%左右,考虑无创呼吸机辅助通气下患儿易烦 躁,改为头罩吸氧 3.24 22:53 患儿出现氧饱和度不稳定,持续下降至50%左右, 刺激反应差,呼吸急促,肤色发绀,末梢循环差, 给予气管插管,高频呼吸机辅助通气,急查胸片示 :右侧气胸较前吸收,左侧气胸明显,行左侧胸腔 置管引流术,促进肺复苏,置入导管,抽出气体后 患儿血氧饱和度升至100%左右,肤色红润,反应 较前好转。 3.25 00:30 患儿左侧胸腔置管间断抽气可抽出多量气体,改为 引流瓶胸腔闭式引流,引流瓶内可见气泡波动。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 病程 3.29 20:20 3.30 00:25 患儿复查胸片回示肺复张可,患儿自主呼吸强烈, 予试拔管,停呼吸机辅助通气,改为箱式吸氧。 患儿胸腔引流管自行脱出,给予引流管处消毒包扎 。患儿胸片检查所见,胸廓对称,气管居中,双肺 纹理增多,双侧膈面光滑,双肋膈角锐利,左侧胸 腔所见引流影。 4.01 患儿箱式吸氧下无青紫,无呼吸暂停,予停止吸氧 。奶量完成可,消化好,予停管饲。 4.10 患儿呼吸平稳,气胸好转,吃奶好,无腹胀及呕 吐,未吸氧下氧和平稳,体温正常,复查各项检查 指 标好转,应家属要求出院。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 辅助检查 血气分析: 入院:PH:7.39,PCO2:37mmHg,PO2;44mmHg, Lac:3.1mmol/L. 3月29日复查:PH:7.52,PCO2:26mmHg,PO2:77mmHg,Lac:1.4mmol/L 胸片: 入院:右肺上野外带肺组织 呈受压状态,下野可见无肺纹理区。 结论 :右 侧气胸。 3月24日急查:气管纵膈右移,双肺野外缘见 无肺纹理组织 区。结论 :双侧 气胸,双侧肺炎。 感染指标: 入院:降钙素原:31.3ng/L;血常规:白细胞:16.67X10^/L;中性粒细胞: 11.31X10^9/L;淋巴细胞:3.28X10^9/L;血红蛋白:159.0g/L;血小板: 260X10^9/L 4月4日复查:降钙素原:0.1ng/L;血常规:白细胞:7.13X10^/L;中性粒细胞 :0.92X10^9/L;C反应蛋白:1.43mg/L;血红蛋白:119.0g/L;血小板: 446X10^9/L With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 药物治疗 1、维生素K1预防新生儿出血。 2、无创呼吸机辅助通气,予以溴己新促进肺液排 除。 3、神经节苷脂营养脑细胞治疗。 4、美罗培南抗感染治疗,足疗程后降级为头孢他啶治 疗。 5、提示心肌损害,予果糖二磷酸钠营养心肌治疗。 6、4月4日改为脑蛋白水解物继续营养脑细胞治疗。 7、禁食,静脉营养液营养支持治疗。 8、患儿住院期间出现黄疸,给予蓝光照射,注意保 护眼部及会阴,并补充核黄素。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society Contents 目录 01 02 03 04 气胸的定义 气胸的病因及分类 临床表现 治疗及护理 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 定义 气胸:因肺泡过过度膨胀胀,直至破裂,气体进进 入胸膜腔,造成积积气状态态 发生率占新生儿的1%-2%,但具有临床症状者仅为 0.05%-0.07%,其发病率在肺透明膜病中为27%,胎 粪吸入中占41%,窒息患儿为25%,湿肺为10% With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 气胸 负压 大于大气压 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 医源性气胸 01 系指由诊断和治疗操作所致的气胸。临床类型可 分为闭合性气胸,交通性气胸和张力性气胸 病理性气胸 02 指发生在有基础疾病的新生儿 自发性气胸 03 发生在无基础疾病的新生儿 新生儿气胸分类: With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 病因 病理性气胸 自发性气胸 医源性气胸 多发生于重度窒息、胎粪吸入综合征并 呼吸衰竭的患儿 在气囊加压给氧,或 给氧、气管插管复苏或机械通气的过程 中发生。 以肺部疾病为主,是由于肺部本身的疾 病所致,多见于足月儿,常有宫内窘迫 或生后窒息史 。 是指在无外伤或人为因素的情况下肺组 织及胸膜发生破裂,引起气胸的新生儿 。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 临床表现 、 01 02 03 04 请在此处输入您的文本 请在此处输入您的文本 极少部分患儿无任何呼吸道症状,仅在 胸片检查时发现;有原发病的患儿还有 相应原发病的表现 经窒息复苏后持续呼吸困难,给氧不能缓解 ,或突然(或原发病稳定后)出现的呼吸困难、 呻吟、烦躁不安 有部分患儿无明显症状或仅表现为呼吸急促, 查体可有不同程度的呼吸困难、紫绀 患侧胸廓隆起,肋间隙饱满,叩诊呈过 清音,听诊呼吸音减弱或消失 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society X线 为诊断气胸最可靠的方法。可显示肺压缩的 程度,肺部情况,有无胸腔积液以及纵隔移位等。 X线表现:外凸弧形的细线条形阴影,系肺组织和 胸膜腔内气体的交界线,线内为压缩的肺组织,线 外见不到肺纹理,透亮度明显增加。气胸延及下部 则肋膈角显示锐利。 辅助检查 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 辅助检查 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 血气分析:显示PaO2降低, PaCO2增大. 透照试验:以高强度纤维光源 两侧对比探查胸部,大量气体 积聚部位透亮度高 辅助检查 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 治疗 排气减压 尽早肺复张 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 保守治疗 症状轻、无明显呼吸困难、气胸量 30% 的闭合性气胸经保守治疗后多可治愈。气胸 量为30%时,24-48小时左右可吸收 抗生素控制感染 排气减压行胸腔闭式引流 呼吸机治疗 01 02 03 04 05 治疗方 法 治疗 治疗原发病和并发症 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 胸腔闭闭式引流 目的:1、引流胸腔内积气、积液和积血;2、重建负 压,保持纵膈正常位置;3、促进肺膨胀。 排气管一般置于锁骨中线第二肋间 排液管一般置于腋中线或腋后线第6~8肋间 脓胸常选在积液最低位 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 护 理 诊 断 2 组织灌注不足 与大面积气胸压迫心脏有关 5 皮肤完整性受损 与气胸穿刺,皮肤受压有关 4 营养失调 :低于身体需要量 与禁食有关 3 体温异常可能 与体温调节中枢发育不完善有关 6 潜在并发症 肺不张、心脏骤停、肺部感染。 1 气体交换受阻 与肺泡壁破裂,健侧肺组织压 有关。 6 5 4 3 2 1 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 护理措施 二、呼吸机的护理 一、胸腔闭式引流的护理 三、一般护理 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 一、胸腔闭式引流的护理 (1)保持引流管通畅 术后予以抬高头位30度利与引流,固定好引流管避免引流管因阻塞 、受压、扭曲、折叠、脱出等原因造成的引流不畅。 定时挤压 引流管,每隔两小时自上而下向水封瓶方向挤压 ,防止血 块堵塞,观察水封瓶中的水柱随呼吸上下波动情况,若水柱波动 不明显或无波动,患者呼吸困难无好转,提示引流管有堵塞的可 能,应及时检查 原因,给予调整或重新放置胸腔闭式引流管。 固定引流管,防止脱落,患儿翻身、叩背或搬运后应检查 引流管是 否有扭曲或受压。水封瓶应牢固安置辐射台或暖箱上,液面要低 于。引流部位60cm以上,水封瓶长管插入水面下2cm,防止水封瓶 倾斜牵拉引流管 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 一、胸腔闭式引流的护理 (2)保持引流系统密闭与无菌 引流系统必须保证处于密闭状态,保证引流管固定牢固、 各个接头连接紧密,防止脱落。 始终保持水封瓶液面低于胸腔平面60cm,水封瓶及瓶内灭 菌注射用水应每日更换一次,更换水封瓶应严格无菌操 作,并用双钳夹紧 近心端管道,引流装置处理维妥后再 松钳,严防气体进入及液体逆流入胸腔。 皮肤切口处应每日用碘伏消毒后无菌敷料覆盖。 (3)观察切口处固定线是否脱落,以及有无红肿、渗液等 炎性症状。观察引流物的量、颜色、性质,并做好记录 。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 一、胸腔闭式引流的护理 (3)拔管护理 胸腔闭式引流后,患儿呼吸困难改善,血气分析恢复正常,x 线 示肺复张,引流管内无气泡逸出,予夹管观察24小时,复查x线示 气胸已吸收,可拔出胸管。 由于患儿引流管自行脱落,请胸外科会诊后,密切观察生命体征 ,必要时再次插管。拔管后皮肤伤口小,不需要凡士林油纱布覆盖 ,用自粘伤口敷料粘贴即可。拔管后24小时要密切观察患儿 有无 呼吸困难,局部穿刺处有无渗血、渗液、红肿 等症状 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (1)使用呼吸机前,仔细检查 各电源线,氧气管道及其连接 ;湿化器加水至标准刻度线;测试呼吸机各种机能及运转情 况;设置呼吸机基础参数。 二、呼吸机的护理 (2)连接气管导管与呼吸机;观察胸部起伏,用听诊器听 诊左右胸前部及两腋下区,以确认气管导管的正常位置及通 畅性,防止单肺通气。 (3)常规监测动 脉血气。 (4)保持呼吸道通畅,及时有效地吸痰。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (5)加强物理治疗,定时翻身拍背,利于分泌物排出。 (6)严防人工气道移位及 意外拔管,新生儿经口腔气管插 管时较难固定,极易移位及滑脱。 (7)掌握各种报警的意义,保证病人的安全。 (8)严密观察病情,注意观察呼吸、心率、体温及尿量的 变化。观察呼吸机参数的变化及患儿对机械通气的反应,并 做好记录。观察并发症,有异常时及时通知医师。 二、呼吸机的护理 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 三、一般护理 1、一般护理:常规保持病室安静,准确执行各项治疗护理 操作,将患儿置于暖箱保暖,抬高床头15~30°,给予心电 监护,动态监测 血气指标。 2、保持呼吸道通畅:患儿肺部大面积压缩 ,肺功能受到严 重影响,为保证机体对气体的需要,需及时清除呼吸道分 泌物,保证呼吸道通畅,给予患侧卧位,定时翻身拍背吸 痰。 3、尽量减少操作,保持安静,必要时给予苯巴比妥或水合 氯醛镇 静,避免哭闹操作尽量集中进行 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 三、一般护理 4、严密观察生命体征:心率、呼吸、血压、spo2和四肢末端皮 肤颜色和温度,反应和肌张力等,一旦出现异常应紧急处理 。 5、保证营养供给:保证静脉营养液的有效输入,防止输液外 渗。遵医嘱留置胃管,酌情配方奶喂养。 6、做好床旁保护性隔离,防止交叉感染,护理操作时尽量集 中进行,气管冲洗后、更换胸腔闭式引流时,均用75%酒精 消毒各接口处再连接,严格无菌操作,做好消毒隔离,特别 是急救、胸腔穿刺时防止感染。保持床单元清洁干燥,每天 给予晨间护理,及时更换床上用物,并严格做到专物专人专 用。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society THANKS TO LISTEN 【谢谢 大家聆听】
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