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第十四章_病情观察及危重患者的抢救和护理课件

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第十四 病情 观察 危重 患者 抢救 护理 课件
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单击此处编辑母版标题样式 单击此处编辑母版副标题样式 1 第十四章 病情观察及危重患者的 抢救和护理 单击此处编辑母版标题样式 单击此处编辑母版副标题样式 2 内容提要 病情观察 危重症患者的管理 常用抢救技术 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 第一节 病情观察 学习目标 病情观察的方法及内容 如何提高病情观察能力 n3 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 案例一 患者 老年女性 糖尿病晚期 由其儿子 陪护 某日下午快下班时 其陪护慌慌张张地 跑进护士办公室 大声喊 快来人 n4 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 案例二 患者 老年男性 酒精性肝硬化 某日 夜里起床上厕所 护士见陪护睡得很死 不 放心就自己跟着患者 只见患者行为非常反 常 n5 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 案例三 青霉素过敏迟缓反应一例 n6 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 一 病情观察的概念 医务人员在诊疗和护理工作中运用视觉 触 觉 听觉 嗅觉等感觉器官及辅助工具来获得患 者信息的过程 n7 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 一 病情观察的意义 1 为疾病的诊断和治疗护理提供依据 2 判断疾病的发展趋向和转归 3 及时了解治疗效果和用药反应 4 及时发现危重患者病情变化 防止病情恶化 n8 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 一定的医学知识 敏锐的观察力 严谨的工作作风 高度的责任心 要做到 五勤 勤巡视 勤观察 勤询问 勤思考 勤记录 二 护理人员应具备条件 n9 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 三 病情观察的方法 直接观察法 1 视诊 inspection 用视觉观察病人全身及局部状态的评估 方法 n10 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 2 触诊 palpation 触诊是通过手的感觉来感知病人身体某部有无 异常的检查方法 通过触诊可以明确视诊不能明确 的异常征象 n11 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 3 叩诊 percussion 通过手指叩击或手掌拍击被检查部位体表 使之震动而产生音响 根据所感到的震动和所听 到的音响特点来了解被检查部位脏器的大小 形 状 位置及密度 n12 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 4 听诊 auscultation 广义的听诊包括听病人发出的语音 咳嗽 呃逆 嗳气 呼吸音 肠鸣音 关节活动音 呼 叫等任何声音 这些声音均可为评估提供有价值 的线索 n13 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 5 嗅诊 smelling 是用嗅觉来辨别发自病人的各种气味及与其 健康状况关系的一种方法 这些气味来自皮肤 粘 膜 呼吸道 胃肠道 分泌物 呕吐物 排泄物 脓液或血液等 n14 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 间接观察法 1 通过与医生 家属的交流 床边和书面交接 班 阅读病历 检验报告 会诊报告及其他相关资 料 获取有关病情的信息 2 借助仪器 如心电监护仪等 n15 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 四 病情观察的内容 1 一般情况的观察 2 生命体征的观察 3 意识状态的观察 4 瞳孔的观察 5 心理状态的观察 6 特殊检查或药物治疗的观察 7 其他方面的观察 n16 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 1 一般情况的观察 发育与体型 发育 development 通常以年龄 身高 体重 智力及第二性征之间的关系来判断 体型 habitus 是身体各部发育的外观表 现 包括骨骼 肌肉的成长与脂肪分布的状态 1 一般情况的观察 n17 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 饮食与营养 营养状态常以皮肤粘膜 皮下脂肪 肌肉 毛发的综合发育情况为营养状态判断依据 临床 上分为良好 不良 中等三个等级 1 一般情况的观察 n18 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 面容与表情 常见典型面容 1 一般情况的观察 急性病容慢性病容 n19 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 二尖瓣病容 1 一般情况的观察 贫血病容 n20 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 甲亢面容 肢端肥大症面容满月面容 粘液性水肿面容 1 一般情况的观察 n21 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 体位 position 常见体位有 自主体位 被动体位 强 迫体位 不同的疾病可使患者采取不同的强迫体 位 对某些疾病的诊断有一定意义 1 一般情况的观察 n22 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 强迫仰卧位 强迫蹲位 强迫俯卧位 强迫坐位 强迫侧卧位 辗转体位 强迫停立位 角弓反张位 1 一般情况的观察 n23 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 姿势 posture 与步态 gait 姿势即举止的状态 步态即走动时所表现的姿态 小脑 锥体外系功能障碍 深感觉 肌力 肌张力异 常等均会影响姿势和步态 1 一般情况的观察 n24 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 皮肤与粘膜 可反映某些全身疾病 主要观察皮肤颜色 温 度 湿度 弹性及有无出血 水肿 皮疹 皮下结 节 囊肿等 1 一般情况的观察 n25 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 3 意识状态的观察 意识障碍 disturbance of consciousness 是指 个体对外界环境刺激缺乏正常反应的一种精神状态 表现为对自身及外界环境的认识及记忆 思维 定向 力 知觉 情感等精神活动的不同程度的异常改变 3 意识状态的观察 n26 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 嗜睡 somnolence 最轻度的意识障碍 患者处于持续睡眠状态 但能被言语或轻度刺激唤醒 醒后能正确 简单而 缓慢地回答问题 但反应迟钝 刺激去除后又很快 入睡 3 意识状态的观察 n27 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 意识模糊 confusion 程度较嗜睡深 表现为思维和语言不连贯 对 时间 地点 人物的定向力完全或部分发生障碍 可有错觉 幻觉 躁动不安 谵语或精神错乱 3 意识状态的观察 n28 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 昏睡 stupor 患者处于熟睡状态 不易唤醒 经压迫眶上 神经 摇动身体等强刺激可被唤醒 醒后答话含 糊或答非所问 停止刺激后即又进入熟睡 3 意识状态的观察 n29 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 昏迷 coma 3 意识状态的观察 n30 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 格拉斯哥昏迷评分量表 P318 Glasgow Coma Scale GCS GCS包括睁眼反应 语言反应 运动反应3个项 目 GCS量表总分范围为3 15分 正常为15分 总分 低于7分者为浅昏迷 低于3分者为深昏迷 3 意识状态的观察 n31 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 瞳孔的形状 大小与对称性 正常 瞳孔 pupil 呈圆形 两侧等大等圆 位置居中 边缘整齐 在自然光线下 直径为2 5mm 调节反射两侧 相等 4 瞳孔的观察 4 瞳孔的观察 n32 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 异常 瞳孔直径 2mm称为瞳孔缩小 1mm 为针尖样瞳孔 双侧缩小 见于有机磷农药 氯 丙嗪 吗啡等药物中毒 单侧缩小 提示同侧小 脑幕裂孔疝早期 4 瞳孔的观察 n33 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 异常 瞳孔直径 5mm为瞳孔散大 见于颅内 压增高 颅脑损伤 颠茄类药物中毒及濒死状态 一侧扩大 固定 提示同侧颅内病变所致的小脑幕 裂孔疝的发生 4 瞳孔的观察 n34 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 异常 瞳孔的形状改变常因眼科疾病引起 瞳孔呈椭圆形并伴散大 常见于青光眼等 呈不规 则形 常见于虹膜粘连 4 瞳孔的观察 n35 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 对光反应 正常瞳孔对光反应灵敏 并于光亮处瞳孔收 缩 昏暗处瞳孔扩大 当瞳孔大小不随光线刺激 而变化时 称瞳孔对光反应消失 常见于危重或 深昏迷患者 4 瞳孔的观察 n36 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 病情观察的要求 重点定向 既有侧重点 又要全面 细致而准确 排除干扰 获取正确结果 认真记录 五 如何提高病情观察能力 n37 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 护理观察的基本方法 1 深入性护理观察 2 对比性护理观察 n横向比较 n纵向比较 3 预见性护理观察 4 先兆性护理观察 5 试验性护理观察 n自己进行试验 n各种检查 留取标本 n38 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 患者男性 脑外伤 入院神志清 一般情况 良好 前两天自己下地活动 第三天早晨护士来 扫床 看见患者坐着显得很 安静 床上被褥 乱 作一团 床单也皱褶不平 而且破了好几处 n39 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 患者 男性 诊断肝硬化 一天夜间不断吐鲜 血 值班医生诊断为上消化道出血 给药后出血不 停止 大夜班护士接班后 细心观察所吐血为鲜红 于是进行肺部听诊和口腔检查 结果无异常 再 考虑到鼻腔 护士将患者由平卧位改为侧卧头低位 观察 发现血液从右侧鼻腔流出 n40 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 案例分析 某护士上小夜班 正在办公室写交班报告 忽然听到一位患者走出病房去上厕所 脚步 声很特别 一脚重一脚轻 于是起身去看 是 一位患动脉硬化高血压的老年患者 n41 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 请讨论 1 这名护士观察到的现象属于病情观察里 的那项内容 2 该案例属于护理观察方法里那种方法 3 如果你是这名护士你会做出和她相同的 举动吗 n42 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 第二节 危重症患者的管理 n43 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 急诊医疗服务体系 Emergency Medical Service System EMSS 院外急救 prehospital emergency medical care 急症抢救 重症监护 intensive care unit ICU 运送 患者 医院内 急 诊 n44 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial n45 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial n46 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 一 抢救工作的组织管理与抢救设备 抢救工作的组织管理 1 建立责任明确的系统组织结构 2 制定抢救方案 3 及时 准确做好各项记录 清晰 全面 4 做好核对工作 急救药物须经两人核对 正确后方可使用 执 行口头医嘱和处方 须 向医生复述一遍 确认 无误后方可执行 抢救 完毕由医生及时补写医 嘱和处方 各种药物的 空安瓿 空输液输血瓶 集中放置 以便统计和 查对 n47 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 5 安排护士参加医生组织的查房 会诊 病例 讨论 6 抢救用物的日常维护 及时清理 归还原处 及补充 保持清洁 整齐 控制交叉感染 7 抢救室内抢救器械和药品的管理 严格执行 五定 制度 即定数量 定点放置 定专人管理 定期消毒灭菌 定期检查维修 室内物品一律不得外借 值班护士班班交接 并作记录 n48 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 抢救设备管理 1 抢救室 n49 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial n50 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 2 抢救床 n51 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 3 抢救车 n52 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 常用急救药品 n53 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 4 急救器械 n54 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 二 危重患者的护理 n55 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 一 危重患者的病情监测 n中枢神经系统监测 n循环系统监测 n呼吸系统监测 n肾功能监测 n体温监测 n56 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 二 保持呼吸道通畅 n57 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 三 加强临床基础护理 n保持良好的个人卫生 n皮肤护理 n维持排泄功能 n保持肢体功能 n做好呼吸咳嗽训练 n58 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial n59 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial n注意患者安全 n保持导管通畅 n60 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 1 态度和蔼 语言贴切 易于理解 举止稳重 操作熟练 2 操作前做简单清晰的解释 3 对呼吸机的使用 做好解释 4 建立有效的沟通方式 四 心理护理 n61 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 5 鼓励患者参与到自我治疗和护理方 法的选择 6 多采取 治疗性触摸 7 鼓励家属及亲友探视 8 减少环境因素刺激 说话 走路 操作 关门轻 n62 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 三 常用抢救技术 基础生命支持术 basic life support BLS n63 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 心肺复苏 Cardiopulmonary Resuscitation CPR 心肺脑复苏 Cardiopulmonary Cerebral Resuscitation CPCR 基础生命支持 basic life support BLS 进一步生命支持 advanced cardiac life support ACLS 延续生命支持 prolonged life support PLS n64 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 三 常用抢救技术 洗胃法 gastric lavage 将洗胃管由口腔或鼻腔插入胃 内 反复灌入洗胃溶液 冲洗胃腔 的方法 n65 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 三 常用抢救技术 人工呼吸器的使用 the use of artificial respirator n66 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 人工呼吸器是通过人工或机械装 置产生通气 对没有呼吸的患者进行 强迫通气 对通气障碍的患者进行辅 助呼吸 达到维持和增加机体通气量 纠正低氧血症的目的 n67 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 简易呼吸器 n68 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial n操作步骤 核对 取合适体位 挤压呼吸囊 抢救者站于患者头顶处 托起下颌 头后仰 扣紧面罩 有规律地挤压呼吸囊 一次可挤压500 1000ml 频率 16 20次 分 n69 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 呼吸机 n70 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 呼吸机是借助机械力量 改变气道或 胸腔压力以维持 控制或辅助病人呼吸运 动的一种治疗工具 它适用于各种原因引 起的呼吸停止和呼吸衰竭的患者 以达到 维持通气量 改善换气功能 减轻和纠正 缺氧及CO2潴留 减少氧气消耗等目的 n71 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 任何一台呼吸机 只有较好的理 解其原理 较充分的掌握其性能 才 能达到满意的疗效 否则 由一个不熟 悉的人操纵一台最现代化的呼吸机 还不如使用一个最简单的呼吸囊安全 n72 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 呼吸机的工作原理 肺泡通气的动力 肺泡 大气压差 利用机械动力建立这种压力差和逆 差 使肺泡充气和排气 n73 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 积水瓶 呼吸机 面板 氧气 机身 湿化器 未画出 n74 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial n75 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial n通气模式 1 辅助 控制通气 A C 适用于无 自主呼吸病人 2 同步间歇指令通气 SIMV 适 用于有一定自主呼吸病人 但很弱 3 自主呼吸通气 SPONT 适用 于自主呼吸较好的病人 n76 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 呼吸机主要参数的设置 n77 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial n报警阈值 呼吸频率过快 25次 分 气道压力过低 8cmH2o 20 30 气道压力过高 54cmH2o 呼出潮气量过高 900ml 呼出潮气量过低 375ml 每分通气量过低 4 0L n78 Five weeks of practice ended in this way and my feelings can only be sum
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本文标题:第十四章_病情观察及危重患者的抢救和护理课件
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