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脑血管护理ppt课件

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脑血管 护理 ppt 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 脑血管病病人的护理 南京同仁医院 神经内科 许素梅 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 脑的分区 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 脑的功能 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 概述 n脑血管疾病 由于各种脑部血管病变所引 起的脑功能缺损的一组疾病的总称 n发病率高 120 180 10万 n致残率高 75 n死亡率高 100万 年 n给家庭和社会带来沉重负担 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 脑的血液供应 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 脑部血液供应图 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 脑血管疾病的分类 n按起病缓急 急性和慢性脑血管疾病 n按性质 出血性 缺血性 蛛网膜下腔出血 脑出血 TIA 脑梗死 脑血栓形成 脑栓塞 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 脑血管疾病的危险因素 n可干预 v高血压 v糖尿病 v心脏病 vTIA或脑卒中病史 v其他 肥胖 无症状 性颈动脉狭窄 酗酒 吸烟 抗凝治疗 脑动脉炎等 n不可干预 v年龄 v性别 v种族 v遗传因素 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 脑血管疾病的病因 n基本病因 1 血管壁病变 1 高血压性脑细小动脉硬化 2 脑动脉粥样硬化为最常见 3 血管先天性发育异常和遗传性疾病 4 各种感染和非感染性动 静脉炎 5 中毒 代谢及全身性疾病导致的血管壁病变 2 心脏病 风湿性心脏病 先天性心脏病 细菌性心内膜炎 心房纤颤等 3 其他原因 血管内异物如空气 脂肪等 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 脑血管疾病的病因 n促发因素 1 血液动力学因素 1 血压过高或过低 如高血压 低血压 血压的急骤波动 2 血容量的改变 血容量不足或血液浓缩可 诱发缺血性脑血管疾病 3 心脏疾病 如心功能不全 心律失常 可诱发脑梗死 2 血液成分改变 如血液粘稠度增高 凝血机制异常 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 脑血管病三级预防 n一级预防 n二级预防 n三级预防 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 14 短暂性脑缺血发作 transient ischemic attack TIA Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial TIA概述 n概念 颈动脉系统或椎 基底动脉系统短 暂但反复发作的供血障碍 导致供血区局 限性神经功能缺失症状 一般每次发作持续数分钟至数小时 24小 时内完全恢复 n短暂性脑缺血发作好发于50 70岁 男性 多于女性 TIA患病率为180 10万 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial TIA病因和发病机制 n微栓子学说 n脑血管的狭窄 痉挛或受压 n血液动力学因素 n血液成分改变 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial TIA临床表现 nTIA基本临床特征 发作性 短暂性 症状24小时内完全缓解 可逆性 症状可完全恢复 一般不留 神经功能缺损 反复性 每次发作出现的局灶症状符 合一定的血管供应区 年龄多在50岁以上 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial TIA临床表现 n颈内动脉系统 病灶对侧单肢无力或不完全 性瘫痪 对侧感觉障碍 眼动脉缺血 短暂的单眼失明 优势半球缺血 可有失语 n椎 基底动脉系统 以眩晕为常见症状 一般不伴耳鸣 特征性的症状 跌倒发作 短暂性全面遗忘症 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 治 疗 n病因治疗 n药物治疗 抗血小板聚集药 阿司匹林 双嘧达莫 噻氯吡 啶 抗凝药物 肝素 钙通道阻滞剂 血管扩张剂 n外科治疗 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 护理诊断及措施 n知识缺乏 1 疾病知识指导 积极治疗原发病 释疾病知识 帮助病人消除的恐惧心理 生活规律 根据身体情况适当参加体育锻炼 戒烟少饮酒 定期门诊复查 应避免各种引起循环血量减少 血液浓缩的因素 如大量呕吐 腹泻 高热 大汗等 以防诱发脑血栓形成 2 饮食指导 给予低脂 低胆固醇 低盐饮食 忌刺激性及辛辣食物 避免暴饮暴食 3 用药指导 在抗凝药物治疗期间 应密切观察有无出血倾向 及时测定出凝血时 间及凝血酶原时间 一旦出现情况及时给予相应的处理 坚持按医嘱服药 不可随意停药或换药 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 21 脑 梗 死 cerebral infarction CI Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 概述 n是指局部脑组织由于血液供应中断而发生 的缺血性坏死或脑软化 n在脑血管疾病中最常见 占60 90 n临床最常见的类型 脑血栓形成 脑栓塞 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 23 脑 血 栓 形 成 cerebral thrombosis CT Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 概 念 n指颅内外供应脑部的 动脉血管壁因各种原 因而发生狭窄或闭塞 在此基础上形成血 栓 引起该血管供血 范围内的脑组织梗塞 性坏死 出现相应的 神经系统症状和体征 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 因 n脑动脉粥样硬化 高血压常与动脉硬化并存 颈动脉脉粥样硬化的斑块脱 落引起的栓塞称血栓 栓塞 n其次为各种病因所致的脑动 脉炎 红细胞增多症 弥漫 性血管内凝血的早期等 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 发病机制 n血栓形成机制 动脉粥样硬化 动脉内膜炎 血管内皮损伤 血小板黏附 白色血栓 TXA2 5 HT PAF 红色血栓 管腔狭窄 闭塞 血流缓慢 停止 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 发病机制 n脑梗死形成机制 脑血流障碍 脑血流降至20ml 100g脑组织 min 时 脑细胞电活动停止 脑血流降至10ml 100g脑组织 min 时 神经细胞膜功能完全衰竭 脑血流完全阻断5 10min 神经细胞膜则发生不可逆损害 因此 要挽救脑组织就必须在不可逆损害发生前的极短时间 内恢复血流 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 发病机制 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 临床表现 n好发于中年以后 多见于50 60岁以上的病人 n起病 较缓 常在安静或休息状态下发病 1 3天达高峰 n先兆 部分病人在发作前有前驱症状 头痛 头晕等 约25 人有TIA发作史 n多数病人无意识障碍及生命体征的改变 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 临床表现 特 别 提 示 因梗死部位不同表现亦异 最常见表现为 失语 偏瘫 偏身感觉障碍 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 临床表现 n颈内动脉系统脑梗死 病灶对侧偏瘫 偏盲 偏身感觉障碍 失语 失认等 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 临床表现 n椎 基底动脉系统 眩晕 呕吐 共济失调 交叉性瘫痪等 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 33 脑 栓 塞 cerebral embolism Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 概 述 n指各种栓子随血流进入颅内动脉系统使血管腔急 性闭塞引起相应供血区脑组缺血坏死及脑功能障 碍 n起病急 在活动中起病 n局限性神经缺失症状多在数秒至数分钟内发展到 高峰 为脑血管疾病中起病最快的一种 n栓子来源 心源性 非心源性 来源不明 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 病理与病理生理 n多见于颈内动脉系统 尤其是左侧大脑中动脉 病理上与脑血栓形成基本相同 n病理生理 栓子突然堵塞动脉 侧支循环不能迅速建立 供血区急性缺血 同时常伴有血管痉挛 故起病 时脑缺血范围较广 症状较严重 当痉挛缓解 栓子碎裂 溶解 侧支循环建立时 症状可有所 缓解 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 临床表现 n发病急骤 症状在数秒或数分钟内达高峰 是血 管病中最快的 n多属完全性中风 栓塞部位继发血栓时病情可逐 渐进展 n可有头痛 局灶性癫痫和不同程度的意识障碍 n神经系统定位体征 n原发病的症状和体征 n易发生梗塞后出血 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 治疗要点 n溶栓治疗 rt PA UK n降纤治疗 巴曲酶 n抗凝治疗 肝素 华法令 n抗血小板治疗 阿斯匹林 波立维 n神经保护剂治疗 依达拉奉 钠络酮 n一般综合治疗 控制血压 降颅内压及脑水 肿 喂养 并发症 早期康复等治疗 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 主要护理诊断 n躯体移动障碍 与脑血管闭塞 脑组织缺血 缺氧使锥体束受损导致肢体 瘫痪有关 n自理能力缺陷综合征 与肢体瘫痪 肢体活动能力丧失有关 n语言沟通障碍 与病变累及大脑优势半球 语言中枢受损有关 n有废用综合征的危险 与肢体瘫痪及未能及时进行肢体康复锻炼有关 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 护理措施 n防止脑部血流量减少 急性期病人绝对卧床休息 取平卧位 避免搬动 以使有 较多血液供给脑组织 头部禁用冰袋或冷敷 以免血管收缩 血流缓慢而使脑血 流量减少 监测血压 使血压维持在略高于病前水平 以免血压过低 而导致脑灌注量减少 使病情恶化 若血压过高或过低应 及时通知医师并配合处理 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 护理措施 n饮食护理 低盐低脂饮食 如有吞咽困难 呛咳者 可予糊状流质 或半流质小口慢慢喂食 必要时给予鼻饲 n心理护理 关心尊重病人 避免刺激和损伤病人自尊 克服急躁和悲观情绪 避免过度依赖 增强病人自我照顾能力和信心 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 护理措施 n用药护理 1 低分子右旋糖酐应用时 可出现发热 荨麻疹等过敏 反应 应注意观察 必要时须做过敏试验 2 服用阿司匹林后注意有无黑便 3 使用抗凝剂和溶栓剂 有无全身皮肤粘膜出血 并 定时测出凝血时间 还需备维生素K 硫酸鱼精蛋白等拮 抗剂等 以便于出血并发症的处理 4 甘露醇 溶解 速度应快 30min内输完 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 护理措施 n促进瘫痪肢体功能的恢复 1 瘫痪肢体关节按摩和被动运动 2 起坐锻炼 抬头 仰卧起坐 床边坐位 双腿下垂 稳坐30 60分 站立 3 步行锻炼 扶助站立 稳站15 30分不疲劳 迈步训练 4 增进日常生活自理能力 鼓励病人做力所能及的事情 患肢肌力改善后 训练手的功能 经顽强训练 1 3年内肢体功能可基本恢复 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 护理措施 n安全护理 防止窒息 防止跌伤 防止烫伤 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 45 脑 出 血 intracerebral hemorrhage ICH Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 概 述 n是指原发性非外伤性脑实质内出血 n好发于50 70岁的中老年人 n脑出血的患病率为112 10万 年发病率为81 10万 n高致死率和高致残率 n死亡的主要原因 脑水肿 颅内压增高 脑疝形成 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 因 n高血压和动脉粥样硬化 最常见 n颅内动脉瘤 n脑动静脉畸形 n其他 脑动脉炎 血液病等 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 高血压 脑微动脉瘤 脑小动脉痉挛 破裂 出血 远端脑组织缺氧坏死 出血 水肿 易出血因素 脑动脉管壁薄弱 大脑中动脉分支呈直角 易形成微动脉瘤 发病机制 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 临床表现 n高血压病史 n多在活动状态下急性发病 迅速进展 n有明显的全脑症状 头痛 呕吐 意识障碍 n血压明显增高 n有神经系统的定位体征 n可有脑膜刺激征 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 临床表现 n壳核出血 内囊外侧型出 血 最常见 v头和眼转向出血病灶侧 呈双眼 凝视病灶 侧 v三偏 出血灶对侧偏瘫 偏身感觉障碍和对侧同向 偏盲 v出血灶在优势半球 可伴 有失语 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 临床表现 n丘脑出血 内囊内侧型出血 v占脑出血15 24 v向外压迫内囊 三偏症状 v向内破入脑室 高热 昏迷 瞳孔改变 v向下扩展 损伤丘脑下部和脑干 出现高 热 上消化道出血 最后继发脑干功能衰 竭而死亡 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 临床表现 n脑桥出血 小量出血 交叉性瘫痪 凝视瘫肢 大量出血常破入第四脑室 昏迷 死亡 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 临床表现 n小脑出血 枕部剧烈头痛 眩晕 频繁呕吐 和平衡障碍 但 无肢体瘫痪 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 临床表现 n脑室出血 原发性指脉络丛血管出血及室管膜下1 5 cm内出血 破入脑室者 原发性脑室出血 占脑出血的3 5 轻型 头痛 呕吐 项强 Kernig征 酷似蛛网膜下腔出血 重型 全部脑室均被血液充满 发病即深度昏 迷 呕吐 瞳孔极度缩小 两眼分离斜视或眼球浮动 四肢弛缓性瘫 可有去脑强直 呼吸深 鼾声明显 体 温明显升高 面部充血多汗 预后严重 多迅速死亡 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 辅助检查 n常规检查 血尿常规 血糖 肾功等 n头部 CT 发病后立即出现高密度影 并可显示血肿的部位 大 小 临近水肿带 有否移位及是否破入脑室 n腰穿 慎重进行 脑脊液压力增高 多呈血性 n血管造影 寻找出血原因 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 诊断要点 n病史 急性起病 症状 脑CT Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 治疗 n急性期治疗原则 防止进一步出血 降低颅内压 控制脑水肿 维持生命体征 防止并发症 适合手术的手术治疗 n恢复期治疗 促进神经机能恢复 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 主要护理诊断 n疼痛 头痛 与出血性脑血管病致颅内压增高有关 n急性意识障碍 与脑出血有关 n躯体移动障碍 与脑血管破裂形成的血肿使锥体束受损导致肢体瘫痪有关 n潜在并发症 脑疝 上消化道出血 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 护理措施 n避免颅内压升高 1绝对卧床休息4 6周 避免搬动 保持环境安静 2避免各种刺激 并限制亲友探视 3患者取侧卧位 颈部抬高15 30 以利颅内静脉回流和 保持呼吸道通畅 4头部置冰袋或冰帽以降低脑代谢 5进行各项诊疗操作 吸痰 鼻饲 导尿等 均需动作轻柔 6避免患者剧咳 打喷嚏 躁动或用力排便 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 护理措施 n观察病情 生命体征 意识和瞳孔的变化 T 发病后迅速出现高热 体温调节中枢受损 应物理降温 吸氧 减少脑耗氧量 体温逐渐升高并呈弛张热 感染 体温下降或不升 病情危重 R 早期呼吸深而慢 如呼吸快而不规则或呈潮式呼吸 呼吸中枢严重受损 呼吸停止 先检查是否痰液阻塞 并迅速排除 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 护理措施 n观察病情 生命体征 意识和瞳孔的变化 P和BP 早期血压代偿性升高 脉搏缓慢而充实 如血压 脉搏大幅度变化 或血压急剧下降 延髓血管中枢受损 病情危重 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 护理措施 n观察病情 生命体征 意识和瞳孔的变 意识 意识障碍进行性加重 颅内有进行性出血 瞳孔 两侧瞳孔针尖般缩小 脑桥出血 两侧瞳孔明显不等大 脑疝早期 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 护理措施 n脑疝观察 脑疝前驱症状 烦躁不安 频繁呕吐 意识 障碍进行性加重 两侧瞳孔不等大 血压进 行性升高 脉搏减慢 呼吸不规则 急救 迅速降颅压 备气管切开包和脑室引流包 保持呼吸道通畅 避免引起颅内压增高的各种因素 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 护理措施 n饮食 v急性脑出血病人在发病24小时内禁食 v此后开始流质饮食 v昏迷者可鼻饲 v保证有足够蛋白质 维生素 纤维素摄入 v一般每日不超过1500 2000ml Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 护理措施 n用药护理 v脱水剂 20 甘露醇250ml 30分钟内滴注完成 限 制每天液体摄入量 一般禁食病人以尿量 加500ml液体为宜 v降压药 根据血压情况调整滴数 血压不能过低 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 护理措施 n皮肤护理 1向家属解释发生压疮的危险因素 协调做好预防皮肤损伤 的措施 2每1 2小时给病人变换体位 操作过程中避免拖 拉 推 等动作 3受压部位给予局部按摩 用软枕或棉垫垫于骨突受压处 4勤换尿垫 保持皮肤清洁 被褥平整干燥 5给高蛋白 高维生素 高热量且营养丰富饮食 以增强机 体抵抗力 6感觉减退的病人注意避免温度过高或过低的物体 避免烫 伤 冻伤 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 保健指导 n告知积极治疗原发病对防止再次发生出血性脑血管疾病的 重要性 n避免精神紧张 情绪激动 用力排便及过度劳累等诱发因 素 指导病人自我控制情绪 保持乐观心态 n教会病人家属测量血压 n饮食宜清淡 摄取低盐 低胆固醇食物 避免刺激性食物 及饱餐 多吃新鲜蔬菜和水果 矫正不良的生活方式 戒 除烟酒 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 71 蛛网膜下腔出血 subarachnoid hemorrhage SAH Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 概述 n概念 是多种病因所致脑底部或脑及脊髓 表面血管破裂 血液直接进入蛛网膜下腔 又称原发性蛛网膜下腔出血 n以先天性动脉瘤多见 n动脉瘤破裂所致者好发于30 60岁 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 临床特点 n突然发病 剧烈头痛 n最具特征体征 脑膜刺激征 n最具特征性检查 腰穿血性脑脊液 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 临床表现 n青壮年多发 n活动或情绪激动时急性发病 n突然剧烈头痛伴恶心 呕吐 可有癫痫发作 一 过性意识障碍 少数可有精神症状 n脑膜刺激征阳性 n少数可见玻璃体膜下片块状出血 n老年人症状不典型 多表现为精神
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