外科创伤患者的护理.ppt

NursingCareofClientExperiencingTrauma 创伤病人的护理 DefinitionofTraumaTraumamorbidity 发病率 andmortality 死亡率 constituteamajorhealthcarechallenge 创伤的发病率和死亡率构成了健康的最大挑战 Althoughsignificantstrideshavebeenmadeincombatingheartdiseaseandselectedcancers traumaticinjurycontinuestobethenumber onekilleroftheyoung Section1Overview Trauma traumaticinjury heartdisease cancer Thenumber onekilleroftheyoung Itisestimatedthattraumaticinjurycausesabout140 000deathsperyear Anadditional57millionpeoplesuffernonfatal 不致命的 injurieseachyear 当肯尼迪乘坐敞蓬轿车驶过德克萨斯州达拉斯的迪利广场 DealeyPlaza 时 遭到枪击身亡 约翰 肯尼迪是美国历史上第四位遇刺身亡的总统 也是第八位在任期内去世的总统 assassination遇刺 暗杀 JohnFitzgeraldKennedy 肯尼迪诅咒curse 1 1941年 约瑟夫的残疾女儿死于失败的脑叶切除手术 2 1944年 约瑟夫长子小约瑟夫 肯尼迪战时死于飞机失事 3 1948年 约瑟夫二女儿凯瑟琳死于飞机失事 4 1963年 肯尼迪总统的第三个儿子出生两天后夭折 5 1963年 约瑟夫二子肯尼迪总统遇刺身亡 6 1968年 约瑟夫三子罗伯特遇刺身亡 7 1983年 罗伯特之子博比因吸毒被判刑 8 1984年 罗伯特之子戴维因过量吸服海洛因死亡 9 1997年 罗伯特之子迈克尔死于滑雪事故 10 1999年 约翰之子小约翰 肯尼迪死于飞机失事 11 2009年 约瑟夫四子爱德华死于脑癌 Traumaticinjuryusuallyoccurssuddenly leavingboththeclientandfamilywithlittletimetoprepareforitsconsequences 创伤发生得太突然 没有任何时间留给病人和家庭来准备承受后果 Nurseprovideavitallinkinboththephysical 生理的 andpsychosocial 心理社会 carefortheinjuredclientandfamily 护士要提供给护士伤员及家庭一个关健的护理不仅是生理上的还包括心理社会的 trafficaccident Incaringfortheclientwhohasexperiencedtrauma nursesmustconsidernotonlytheinitialphysicalinjury butalsoitslong termconsequences includingrehabilitationandtheclient sreturntohisorherpreviouswayoflife 护士护理创伤人员时 不仅必须考虑最原先的生理创伤 而且也要考虑长期的后序治疗 包括康复和伤员能回归原来的生活轨道 TypesofTrauma创伤类型 Severity严重程度分类Whetherintentionaloraccidental traumacausesinjurytooneormorepartsofthebody 1Minortrauma 2Majorormultipletrauma 1Minortrauma轻伤 Minortraumacausesinjurytoasinglepartorsystemofthebodyandisusuallytreatedinthehospitaloremergencydepartment 轻伤导致身体一个部分或一个系统的损伤 通通都会在医院或急诊科被治疗 Afractureofthecollarbone asmallsecond degreeburn andacutrequiringstitchesareallconsideredminortrauma 锁骨的骨折 二度烧伤和一个需要缝合的伤口都被认为是轻伤 2Majorormultipletrauma重伤及多发伤 Majorormultipletraumainvolvesserioussingle systeminjury suchasthetraumaticamputationofaleg ormultiple systeminjuries Multipletraumarequiresimmediateintervention 立即干预 thatisspecificallyfocusedonensuringthesurvivaloftheclient 多发伤需要立即干预 尤其重心是保证病人的生命 Clientswhosuffermultipletraumareceiveimmediateemergencycareandoftenrequirelongperiodsofintensivenursingcare 多发创需要立即接受急救治疗 并且经常需要常长时间的护理 TypesofTrauma SkinIntegrality按皮肤的完整性来分1Blunttrauma闭合性损伤Blunttraumaoccurswhenthereisnocommunicationfromthedamagedtissuestotheoutsideenvironment 2Penetratingtrauma开放性损伤Penetratingtraumaoccursastheresultofforeignobjectssetinmotion Penetrationoftissuescausesdamagetobodystructures mostcommonlytheintestines 肠道 liver 肝脏 spleen 脾脏 andvascularsystem 血管系统 TypesofTrauma Organandlocation创伤器官和部位分traumaofabdomen腹部创伤traumaofbladder膀胱损伤 膀胱外伤traumaoflimbs四肢损伤Traumaofchest胸部损伤traumaofbreast乳腺外伤traumaofgastrointestinaltract胃肠道创伤traumaofnose鼻外伤traumaofbrain脑外伤traumaofspinalcord脊髓外伤 EffectsofTraumaticInjury创伤的影响 CausesandInitialManagement创伤原因和处理Airwayobstruction气道阻塞Tensionpneumothorax张力性气胸Hemorrhage出血Integumentaryeffects皮肤损伤Hypovolemicshock低血容量性休克Neurologiceffect对神经系统的影响Effectonthefamily对家庭的影响 1CausesandInitialManagement创伤原因和处理 1 NaturalDisastersEarthquake地震Mudslide mudflow泥石流volcano火山 v l kein u lahar火山泥流 l h avalanche雪崩 v l nt Blizzard暴风雪 bl z d Hurricane飓风Typhoon tai fu n 台风Flood洪水icestorm冰雹 1CausesandInitialManagement创伤原因和处理 Man madedisastersDerail火车出轨Trafficcrash trafficaccident交通事故Planecrash飞机失事attack slaughter fight袭击 屠杀 打架terroristattack恐怖袭击Shooting枪击War battle战争 战斗Sportactivity InitialManagement Amentionedastheopeningofthischapter deathisacommonresultofserioustraumaticinjury Deathfromtraumamaybeimmediate early orlate 创伤引起的死亡可以是立即的 早期的或是晚期的 Immediatedeathisdeathisdeathatthescenefromsuchinjuriesasatornthoracicaorta 主动脉撕裂伤 Earlydeathisdeathoccurringwithinseveralhoursoftheinjuryfrom forexample shock 休克 orlackoftreatmentforunrecognizedinjuries 无法诊断的损伤 Latedeathgenerallyoccursoneormoredaysaftertheinjuryandresultsfrommultipleorganfailure 器官衰竭 Becauseoftheseriousconsequencesofatraumaticinjury itisimportanttoidentifyrapidlyandtakeinterventionsappropriately 因为创伤的严重后果 对于迅速确定并且适当地采取措施非常重要 EP10mins急救白金十分钟 platinum pl tn m CRASHPLAN 检查顺序 Ccardic心脏Rrespiratory呼吸Aabdomen腹部Sspine脊柱Hhead头颅PPelvic骨盆L1imb四肢Aartery血管Nnerve神经 2Airwayobstruction气道阻塞 Thetraumaclient sairwaymaybecomeobstructedbythepresenceofblood teeth thetongue andvomitus 呕吐 Airwayinterventionsmayinclude 1Clearingtheairwaybysuctioning 吸引 2Useofairwayadjuncts suchasanoropharyngeal 口咽的 airway3Intubationwithanoralendotrachealairway 气管插管 4Needleorsurgicalcircothyroidotomy 气管切开 Thisprocedureisperformedonlyafterothermethodsareineffectiveinopeningandmaintaininganopenairway 开放气道Airway Clearingtheairwaybysuctioning anoropharyngealairway 口咽管 Intubationwithanoralendotrachealairway circothyroidotomy 3Tensionpneumothorax张力性气胸 Apneumothoraxresultsfromairinthepleuralspacefrombluntandpenetratinginjuriestothechest Whenaonewayvalve 阀门 iscreatedsothataircanenterthepleuralspacebutnotexit atensionpneumothoraxmaydevelop 4Hemorrhage出血 1ExternalHemorrhage 外出血 Whentheclienthassufferedaninjurythatcausesexternalhemorrhage suchasseveringofanartery thebleedingmustbecontrolledimmediatelymethodstoachievethisinclude 1 Applyingdirectpressureoverthewound 2 Applyingpressureoverarterialpressurepoints压迫伤口上方动脉 3 Elevatingtheinjuredlimb抬高 4 Clampingthebleedingvessel 固定 夹紧 5 Applyingatourniquet 止血带 压迫止血Applyingdirectpressureoverthewound 包扎止血Clampingthebleedingvessel Applyingpressureoverarterialpressurepoints压迫伤口上方动脉 4Hemorrhage出血 2InternalHemorrhage内出血Internalhemorrhagemayresultfromeitherbluntorpenetratingtraumaticinjury Discoveringthecauseof locationof andextentofbloodlossrelatedtotheinjuryisthemostimportantconcerns Methodstodiscoverthepresenceandlocationofinternalhemorrhageinclude Diagnosticperitoneallavage 诊断性腹腔清洗 CTscansofthehead chest andabdomen Diagnosticperitoneallavage Thebodyhasseveralpotentialspacesthatcanaccommodate 容纳 largeamountofbloodthatmayaccumulate 集聚 followinjury 在身体中有几个潜在的腔隙可以容纳大量的血液 Foxexample bleedingintothepleuralspace 胸膜腔 mayoccurwithchesttrauma andbleedingintotheabdominalcavity 腹腔 mayoccurwithabdominaltrauma Pelvicfracture 骨盆骨折 maycausemassivehemorrhageintheretroperitoneal 腹膜后 region Oncethesourceofinternalhemorrhagehasbeenrecognized interventionsareinitiated including Operativecontrolofbleeding手术控制出血Continualassessmentoftheclient includingphysicalassessment vitalsigns andseriallaboratorywork 评估患者通过身体检查 生命体征和一系列的辅助检查 5Hypovolemicshock低血容量性休克 Aseriousandpotentiallylethalcomplicationofexternalorinternalhemorrhageishypovolemicshock Themostcommoncauseofhypovolemicshockistraumainjury Theclientwhohassufferedmultipleinjuriesmaydevelopshockfromacombinationofmultiplesourceofbloodandfluidloss Careoftheclientwhoisexperiencinghypovolemicshockmayincluderapididentificationofthesourcebleeding fluidreplacement bloodtransfusion andoperativeinterventiontocontrolbleeding 6Integumentaryeffects皮肤损伤 Fourspecificinjuriestotheintegumentincludecontusions 挫伤 abrasions 擦伤 puncturewounds 刺伤 lacerations 裂伤 bulletwound Stabbingwound contusions puncturewounds abrasions lacerations Injuriestotheintegument 表皮 areatriskforcontamination 污染 fromdirt debris orforeignobjects Interventionforinjuriestotheintegumentinclude 1Controllinganyactivebleeding2Immobilizingtheaffectedarea 固定 3Stabilizinganypenetratingobjects 固定 4 Cleaningthewound 5 Applyingtheappropriatedressing6 Administeringtetanus 破伤风 immunizationasindicated7 Providinginformationabouthomewoundcarewhentheclientisdischarged 7Neurologiceffect神经系统影响 Headinjuriesareoneofthemostcommontypesofinjurysustained 承受 astheresultoftrauma Injurytothespinalcordresultinginlossofneurologicfunctionisoneofthemostdevastatingoutcomes 破坏性后果 Themajorityofheadandspinalcordinjuriesresultfromblunttraumaandsustainedinmotorvehiclecrash 车祸 Fall 摔倒 sportinjuries 运动损伤 andassault 斗殴 aresomeoftheothersourcesofneurologicinjury 8Effectonthefamily对家庭的影响 Traumaticinjuryusuallyoccurssuddenlyandwithlittlewarning Itmayresultindeathorcauseinjuryseriousenoughtoalterdramaticallyboththeclientsandthefamilylives Signsandsymptomsofpsychologiccrisisincludethefollowing 1shock2Fear3Numbness4Anxiety5Guilt6Hostility 敌对的 7Anger 8Effectonthefamily对家庭的影响 Immediateinterventionsinclude 1Establishingcommunicationwiththefamilyasquicklyaspossible 2Providinginformationaboutclient theincident andthecare 3Accompanyingthefamilytoseetheclient Section2Nursingcareofclientwithtrauma NursingDiagnosesandCollaborativeProblemsNursingcareoftheclientwhohasbeeninjuredbeginswithaprimaryassessmentandtheinitiationofcollaborativeinterventionsforanylife threateninginjuries Nursingcareisdirectedtowardtheclient sspecificresponsestrauma Nursingdiagnosesfortheclientwithtraumamayinclude NursingDiagnosesandCollaborativeProblems 1ImpairedairwayClearancerelatedtotheblockofairwaycausedbytrauma 2Riskforinfectionrelatedtotrauma3Impairedphysicalmobilityrelatedtothepaincausedbytrauma4Spiritualdistress5Post traumaresponse6Riskfortrauma NursingIntervention Theclientwhohassufferedmultipleisatgreatriskfordevelopingairwayobstructionandapnea 窒息 Facialinjuries looseteeth blood andvomitus 呕吐物 increasetheriskforaspiration 误吸 andobstruction Neurologicinjuriesandcerebraledema 脑水肿 altertheclient srespiratorydriveandabilitytokeeptheairwayclear Nursesshouldobservewhethertheclient sairwayispatent 张开的 maintainable 可维持的 Assesstheclientforsignsandsymptomsofairwayobstruction 1Facialtrauma2Debris 异物 intheairway suchasteeth blood orvomitus3Stridor 喘鸣 4Tachypnea 呼吸急促 5Bradypnea 呼吸缓慢 6Cough 咳嗽 7Cyanosis 紫绀 8shortnessofbreath 9Decreasedorabsentbreathsounds Nursesalsoneedtomonitoroxygensaturation Oxygenflowisadjustedtomaintaintheclient soxygensaturationfrom94 100 Riskforinfection Traumaticinjuriesareconsidereddirtywounds Thetraumaoftenoccursinadirtyenvironment Nursinginterventionwithrationales 基本理论 areasfollows 1Usecarefulhandwashingpractices Handwashingremainsthesinglemostimportantfactorinpreventingthespreadofinfection 2Usestrictuniversalprecautions 全面防护 Theuseofuniversalprecautionsisessentialinprotectingtheclientandthenursefrominjection 3Whenapplyingorchangingdressings 敷料 usestrictaseptictechnique 4Takeandrecordvitalsigns5Provideadequatefluidsandnutrition 6Usestrictaseptictechniquewheninsertingcatheters suctioning administeringparenteral 肠外的 medications orperforminganyotherinvasiveprocedure Impairedphysicalmobility Theclientwithtraumaticinjuriesisoftenunabletochangepositionsindependentlyandisatriskforcomplicationoftheintegumentrary 表皮 cardiovascular 心血管 gastrointestinal 胃肠道 respiratory 呼吸 musculoskeletal 肌肉骨骼 andrenalsystems 泌尿系统 Nursinginterventionwithrationalesareasfollowed1Provideactiveorpassiveexercisesatleastonceevery8hours 2Turn cough anddeepbreathatleastevery2hours 3Monitorthelowerextremitieseachdayformanifestationofdeepveinthrombosis Spiritualdistress Traumagenerallystrikeswithlittleorwarningandcarriespotentiallydevastating 破坏 consequencesrangingfromseverealterationsinthelivesofthevictimandfamily todeath Thetraumaticdeathofalovedonemaybethemostdifficulteventafamilymayeverexperience Providingthefamilywithresourcesthatmaybeusedinthefuturemayhelppreventfuturecrisesanddysfunction Post traumaresponse Post traumaresponseisanintense sustainedemotional responsetoadisastrousevent Thisresponseischaracterizedbyemotionsthatrangefromangertofearandbyflashbacksorpsychicnumbing 反应麻木 Intheinitialstage theclientmaybecalmormayexpressfeelingofanger 生气 disbelief 不信任 terror 恐怖 andshock 惊吓 Inthelong termphase theclientoftenexperiencesflashbacks 闪回 andnightmares 恶梦 ofthetraumaticevent Theclientmaycallonineffectivecopingmechanisms suchastheuseofalcoholordrugs andwithdrawfromrelationshipwithothers 患者也许会求助于不积极的妥协机制就像运用酒精和药物或者避开人群 Post traumaticstressdisorder创伤后应激障碍 美国911恐怖袭击 虽然它已经过去了10年 但那些曾经亲生经历或亲眼目睹这一悲剧的人们 似乎还未能从中走出来 有一部分人躲过了911那一场劫难 现在却在承受着身体和心理上的另一场煎熬 有研究报告显示 当初参与911救援的消防人员罹患癌症的几率比常人高 一部分民众一直受到创伤后应激障碍 PTSD 的困扰 Nursinginterventionwithrationalesareasfollows 1Assesstheclient semotionalresponseswhileprovidingphysicalcare Observeforcrying suspiciousness andfearduringtheinitialphaseoftreatment 当提供护理的时候评估患者的情况反应 并且在治疗阶段的时候观察是否有哭泣 怀疑和恐惧 2Beavailableiftheclientwishestotalkaboutthetrauma andencouragetheclienttoexpresshisorherfeelingwhentheclientseemsreadytodoso 如果患者愿意讨论创伤是被允许的 并且鼓励患者愿意表达他或她的感觉当如患者看起来已经做好了准备 Theclientmayinitiallydenynegativefeeling thisdenialisacopingmechanismintheinitialphaseofrecovery 患者刚开始也许会否认消极的感觉 这种否定是一种恢复起始阶段的合作机制 3Teachrelaxationtechniques suchasdeepbreathing progressivemusclerelaxation orimagery 教给放松技术 就如深呼吸 渐渐的肌肉放松和想象 4Refertheclientandfamilymembersforcounseling 咨询 psychotherapy orsupportgroupsasappropriate Continuedtherapymaybenecessaryinallowingtheclientandfamilytoresolvetheacuteandlong termeffectsoftrauma 患者和家庭成员的咨询 心理治疗或者群组支持是适当的 连续的治疗可能是必要的 允许患者或家庭解决短期或长期的创伤影响 Iftheclientisunconscious encouragefamilymembersandfriendstoexpresstheirfeeling Theseassessmentsprovidevaluableinformationabouttheclient sabilitytocopewiththetrauma 如果患者是不清醒的 鼓励家庭成员和朋友让他们表达感情 这些评估会提供关于患者处理创伤的能力的有价值的信息 ThankYou