危重病人的病情觀察及搶救護(hù)理

1、PowerpointTemplate,QQ:378700000,,,,,何為病情觀察？,,,即護(hù)理人員在工作中積極啟動(dòng)視、聽(tīng)、嗅、觸等感覺(jué)器官及輔助工具來(lái)獲得有關(guān)病人及其情境的信息過(guò)程；觀察病情變化是護(hù)理工作的一項(xiàng)重要內(nèi)容，是一項(xiàng)系統(tǒng)工程，它貫穿于護(hù)理的全過(guò)程。,,直接觀察法:利用感覺(jué)器官觀察病人的方法包括視診、聽(tīng)診、觸診、叩診、嗅診護(hù)士用自己的眼睛看、耳朵聽(tīng)、鼻子嗅、雙手觸摸來(lái)觀察患者的意識(shí)、行為、生理、病理變化等，這

2、是觀察病情最基本的方法。,病情觀察的方法,,,,,,間接觀察法 :醫(yī)生、家屬交流、交接班閱讀病歷、檢驗(yàn)報(bào)告借助儀器，如心電監(jiān)護(hù)儀,血糖檢測(cè)儀etc、,A,B,,,,,,,,,,,,,,意識(shí)狀態(tài),生命體征,呼吸功能,瞳孔,一般情況,心理狀態(tài),循環(huán)功能,腦功能,特殊檢查或藥物治療,,,一般情況的觀察,,面容與表情,,皮膚與粘膜,,姿勢(shì)與體位,,排泄物、嘔吐物及引流液,,,,,,面容與表情急性病容？慢性病容？二尖瓣面容？貧血面容 ？,

3、皮膚與粘膜主要觀察皮膚的彈性、顏色、溫度、濕度、有無(wú)出血、水腫、黃疸和發(fā)紺、皮疹、皮下結(jié)節(jié)、囊腫等情況。,姿勢(shì)與體位急性腹痛時(shí)，患者彎腰捧腹，雙腿踡曲，借以減輕病痛；患有胸膜炎或胸腔積液的患者，往往取患側(cè)臥位，以減輕疼痛，有利呼吸,排泄物、嘔吐物及引流液排泄物包括糞、尿、汗液、痰液等，護(hù)士應(yīng)仔細(xì)觀察排泄物和嘔吐物的性狀、顏色、數(shù)量與氣味等。并作好記錄，必要時(shí)收集標(biāo)本送檢，以協(xié)助診斷。引流時(shí)應(yīng)觀察各種引流液的量、性質(zhì)的變化以及引流管

4、是否通暢。,生命體征的觀察,,ADD YOUR TITLE,應(yīng)觀察溫度高低、熱型及其伴隨癥狀。若體溫低于35℃或突然升高達(dá)40℃以上提示病情嚴(yán)重,脈搏，應(yīng)觀察頻率、節(jié)律和強(qiáng)弱。如脈搏少于60次/min或多于140次/min 出現(xiàn)間歇脈、脈搏短絀，均說(shuō)明病情有變化。,應(yīng)觀察呼吸的頻率、節(jié)律、深淺度、呼吸的聲音以及有無(wú)呼吸困難、呼吸道梗阻等。呼吸嚴(yán)重抑制時(shí)，可出現(xiàn)點(diǎn)頭樣呼吸或潮式呼吸成人呼吸頻率超過(guò)40次/min或少于8次/mi

5、n，都是病情嚴(yán)重的征象。,呼 吸,對(duì)高血壓和休克患者的血壓觀察有特殊意義。,意識(shí)的觀察,,,,嗜睡,,意識(shí)模糊,,昏睡,是輕度的意識(shí)障礙。病人持續(xù)地處于睡眼狀態(tài)，能被喚醒，醒后能正確回答問(wèn)題，但反應(yīng)遲鈍，停止刺激后很快入睡。,意識(shí)障礙程度較嗜睡深，對(duì)周?chē)h(huán)境漠不關(guān)心，答話簡(jiǎn)短遲鈍，表情淡漠，對(duì)時(shí)間、地點(diǎn)、人物的定向力完全或部分障礙。,接近不省人事的意識(shí)狀態(tài)，病人處于熟睡狀態(tài)，不易喚醒。較強(qiáng)刺激可被喚醒，醒后答非所問(wèn)，且很快又入睡,淺昏

6、迷：意識(shí)大部分喪失，無(wú)自主運(yùn)動(dòng)。瞳孔對(duì)光反射、角膜反射、吞咽反射、咳嗽反射存在。生命體征無(wú)明顯變化，可有大小便失禁或潴留。,深昏迷：意識(shí)完全喪失，對(duì)各種刺激無(wú)反應(yīng)。全身肌肉松弛，四肢癱軟，深淺反射均消失，偶有深反射亢進(jìn)和病理反射出現(xiàn)，機(jī)體僅能維持呼吸、循環(huán)，但生命體征不穩(wěn)定，大小便失禁或潴留。,,,昏迷,,,,,瞳孔,,正常人瞳孔雙側(cè)等大，呈圓形居中，邊緣整齊，在自然光線下直徑約為2.5～4mm。瞳孔散大（直徑＞5mm），常見(jiàn)于顛茄類

7、藥物反應(yīng)、顱內(nèi)壓增高及瀕死期病人；瞳孔縮?。ㄖ睆剑?mm），常見(jiàn)于有機(jī)磷農(nóng)藥、巴比妥及嗎啡類藥物中毒等；一側(cè)瞳孔散大常見(jiàn)于腦疝、腦腫瘤、腦出血壓迫一側(cè)動(dòng)眼神經(jīng)等。,正常人瞳孔對(duì)光反應(yīng)靈敏，若瞳孔大小不隨光線刺激而變化，稱瞳孔對(duì)光反應(yīng)消失，常見(jiàn)于深度昏迷或?yàn)l死期病人。,循環(huán)功能的觀察,休克指數(shù)＝心率/收縮壓的比值，表示血容量正?！　?.5為正?！　。?為輕度休克，失血20％－30％　　>1為休克　　>1.5為嚴(yán)重休克，

8、失血30％－50％　　>2為重度休克，失血>50%心肌耗氧=心率×收縮壓的積＜12000平均血壓：舒張壓+1/3脈壓=60-100MMHG中心靜脈壓（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，負(fù)荷過(guò)大,呼吸功能監(jiān)測(cè),,肺泡通氣量：是指靜息狀態(tài)下單位時(shí)間內(nèi)進(jìn)入肺泡的新鮮空氣量肺泡通氣量和血流比比值大——灌注不足（無(wú)效通氣）比值小——通氣不足（無(wú)效灌

9、注）氧飽和指數(shù)動(dòng)脈血?dú)夥治鰌aO2（動(dòng)脈血氧分壓） 為80~100mmHg。,肺泡通氣量：是指靜息狀態(tài)下單位時(shí)間內(nèi)進(jìn)入肺泡的新鮮空氣量肺泡通氣量和血流比比值大——灌注不足（無(wú)效通氣）比值小——通氣不足（無(wú)效灌注）氧飽和指數(shù)動(dòng)脈血?dú)夥治鰌aO2（動(dòng)脈血氧分壓） 為80~100mmHg。,腦功能監(jiān)測(cè)——顱內(nèi)壓,臨床多用癥狀觀察法：腦膜刺激癥狀、頭痛、嘔吐、球結(jié)膜水腫、視N乳頭水腫等,臨床多用癥狀觀察法：腦膜刺激癥狀、頭痛、

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