危重病人病情观察及抢救护理

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,危重病人病情观察及抢救护理,何为病情观察？,即护理人员在工作中积极启动视、听、嗅、触等感觉器官及辅助工具来获得有关病人及其情境的信息过程；,观察病情变化是护理工作的一项重要内容，是一项系统工程，它贯穿于护理的全过程。,直接观察法,:,利用感觉器官,观察病人的方法包括视诊、听,诊、触诊、叩诊、嗅诊,护士用,自己的眼睛看、耳朵听、鼻子,嗅、双手触摸来观察患者的意,识、行为、生理、病理变化等，,这是观察病情最基本的方法。,病情观察的方法,间接观察法,:,医生、家属交流、,交接班,阅读病历、检验报告借助仪器，如心电监护仪,血糖检测仪,etc,、,A,B,病情观察的内容,意识状态,生命体征,呼吸功能,瞳孔,一般情况,心理状态,循环功能,脑功能,特殊检查或药物治疗,一般情况的观察,1,面容与表情,2,皮肤与粘膜,3,姿势与体位,4,排泄物、呕吐物及引流液,面容与表情,急性病容？,慢性病容？,二尖瓣面容？,贫血面容,？,皮肤与粘膜,主要观察皮肤的弹性、颜色、温度、湿度、有无出血、水肿、黄疸和发绀、皮疹、皮下结节、囊肿等情况。,姿势与体位,急性腹痛时，患者弯腰捧腹，双腿踡曲，借以减轻病痛；患有胸膜炎或胸腔积液的患者，往往取患侧卧位，以减轻疼痛，有利呼吸,排泄物、呕吐物及引流液,排泄物包括粪、尿、汗液、痰液等，护士应仔细观察排泄物和呕吐物的性状、颜色、数量与气味等。并作好记录，必要时收集标本送检，以协助诊断。引流时应观察各种引流液的量、性质的变化以及引流管是否通畅。,生命体征的观察,ADD YOUR TITLE,体 温,脉 搏,血 压,应观察温度高低、热型及其伴随症状。若体温低于,35,或突然升高达,40,以上提示病情严重,脉搏，应观察频率、节律和强弱。如脉搏少于,60,次,/min,或多于,140,次,/min,出现间歇脉、脉搏短绌，均说明病情有变化,。,应观察呼吸的频率、节律、深浅度、呼吸的声音以及有无呼吸困,难、呼吸道梗阻等。呼吸严重抑制时，可出现,点头样呼吸或潮式呼吸成人呼吸频率超过,40,次,/min,或少于,8,次,/min,，都是病情严重的征象。,呼 吸,对高血压和休克患者的血压观察有特殊意义。,意识的观察,嗜睡,意识模糊,昏睡,是轻度的意识障碍。病人持续地处于睡眼状态，能被唤醒，醒后能正确回答问题，但反应迟钝，停止刺激后很快入睡。,意识障碍程度较嗜睡深，对周围环境漠不关心，答话简短迟钝，表情淡漠，对时间、地点、人物的定向力完全或部分障碍。,接近不省人事的意识状态，病人处于熟睡状态，不易唤醒。较强刺激可被唤醒，醒后答非所问，且很快又入睡,浅昏迷：意识大部分丧失，无自主运动。瞳孔对光反射、角膜反射、吞咽反射、咳嗽反射存在。生命体征无明显变化，可有大小便失禁或潴留。,深昏迷：意识完全丧失，对各种刺激无反应。全身肌肉松弛，四肢瘫软，深浅反射均消失，偶有深反射亢进和病理反射出现，机体仅能维持呼吸、循环，但生命体征不稳定，大小便失禁或潴留。,昏迷,瞳孔,1.,形状、大小和对称性,2.,对光反应,正常人瞳孔双侧等大，呈圆形居中，,边缘整齐，在自然光线下直径约为,4mm,。瞳孔散大（直径,5mm,），常见于颠茄类药物反应、颅内压增高及濒死期病人；瞳孔缩小（直径,2mm,），常见于有机磷农药、巴比妥及吗啡类药物中毒等；一侧瞳孔散大常见于脑疝、脑肿瘤、脑出血压迫一侧动眼神经等。,正常人瞳孔对光反应灵敏，若瞳孔大小不随光线刺激而变化，称瞳孔对光反应消失，常见于深度昏迷或濒死期病人。,循环功能的观察,休克指数心率,/,收缩压的比值，表示血容量正常,为正常,1,为轻度休克，失血,20,30,1,为休克,为严重休克，失血,30,50,2,为重度休克，失血,50%,心肌耗氧,=,心率,收缩压的积,12000,平均血压：舒张压,+1/3,脉压,=60-100MMHG,中心静脉压（,VCP,）,正常值：,5-12CMH2O,小于,5,右心充盈不佳，血容量不足,大于,15-20,右心功能不良，负荷过大,呼吸功能监测,肺泡通气量：是指静息状态下单位时间内进入肺泡的新鲜空气量,肺泡通气量和血流比,比值大,灌注不足（无效通气）,比值小,通气不足（无效灌注）,氧饱和指数,动脉血气分析,paO2,（动脉血氧分压）,为,80100mmHg,。,肺泡通气量：是指静息状态下单位时间内进入肺泡的新鲜空气量,肺泡通气量和血流比,比值大,灌注不足（无效通气）,比值小,通气不足（无效灌注）,氧饱和指数,动脉血气分析,paO2,（动脉血氧分压）,为,80100mmHg,。,脑功能监测,颅内压,临床多用症状观察法：脑膜刺激症状、头痛、呕吐、球结膜水肿、视,N,乳头水肿等,临床多用症状观察法：脑膜刺激症状、头痛、呕吐、球结膜水肿、视,N,乳头水肿等,心理观察,情绪状态的观察,压力及应对的观察,社会状况的观察,认知能力的观察,特殊检查和药物治后的观察,特殊检查后的观察： 防止并发症的发生；,一些治疗方法时病人的观察： 观察治疗是否有效、有无并发症；,药物治疗病人的观察：观察药物治疗的效果,及毒副反应。,Cycle Diagram,ADD YOUR TITLE,TEXT,TEXT,TEXT,TEXT,TEXT,TEXT,Diagram,YOUR TITLE,YOUR TITLE,YOUR TITLE,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,Diagram,ADD YOUR TITLE,welcome to use these powerpoint templates,welcome to use these powerpoint templates,welcome to use these powerpoint templates,welcome to use these powerpoint templates,Diagram,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,A,B,Diagram,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,Diagram,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,Diagram,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,Diagram,TITLE,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,Diagram,ADD YOUR TITLE,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,Diagram,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates,welcome to use these powerpoint templates,Diagram,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,ADD YOUR TITLE,Diagram,Title1,Title2,Title3,Title4,A,B,C,D,E,F,Diagram,2006,2007,2008,2009,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,Diagram,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,Diagram,ADD YOUR TITLE,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,Diagram,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,ADD YOUR TITLE,ADD YOUR TITLE,welcome to use these powerpoint templates, New Content design, 10 years experience,welcome to use these powerpoint templates, New Content design, 10 years experience,Thank You !,Thank You !,不尽之处，恳请指正！,